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    HESI RN HEALTH ASSESSMENT PROCTORED EXAM

    An older adult client who reports pain in the arms and back is brought to the emergency department (ED) by an adult child who states the client "fell out of a chair." The nurse notes that the client has been in the ED five times in the last year for a variety of superficial injuries. Which nursing action has the highest priority?

    Explanation & Rationale

    A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.

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