The nurse is working in the emergency department interacting with clients of various disease processes and injuries. When completing a head-to-toe assessment, which standard assessment technique is most important?

Question

A) Complete the assessment in a structured format.
B) Instruct the client on what you will be doing.
C) Maintain standard precautions throughout the exam.
D) Ask permission to complete an assessment.

Answer 1

C
Feedback:
The most important standard is to maintain standard precautions to protect both the client and nurse. Completing the assessment in a standard format has benefits to ensure that no assessment point is forgotten; however, in an emergency situation, a focus system assessment may be necessary. Instructing the client and asking permission during the assessment is important but may be eliminated when necessary during an emergency situation.