An unlicensed assistive worker tells the registered nurse that a patient who was walking independently is now unsteady and has slurred speech. What should the registered nurse do first?
Correct answer: A. Assess the patient immediately for an acute change
- A. Assess the patient immediately for an acute change
- B. Ask the worker to help the patient walk to the bathroom
- C. Tell the worker to record the finding after the next round
- D. Ask the worker to offer water and reassess the patient later
Explanation
Sudden unsteadiness and slurred speech may indicate an acute neurological event. The registered nurse must assess the patient promptly because assessment and clinical judgement cannot be delegated. Walking the patient could increase injury risk and delay urgent treatment.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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