A nurse receives a verbal report that a patient has become newly confused. What should the nurse do first?
Correct answer: B. Assess airway, breathing, circulation and immediate safety
- A. Record the report and reassess the patient at the next round
- B. Assess airway, breathing, circulation and immediate safety
- C. Ask the family to explain whether confusion is usual
- D. Complete routine documentation before seeing the patient
Explanation
Acute confusion may signal hypoxia, poor perfusion, hypoglycaemia or another urgent problem, so immediate assessment and safety take priority. Documentation, family information and routine tasks follow the initial assessment and stabilisation.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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