Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a "Who Do You See First" Question.
Terminology that is used here is often phrased as, "Who does the nurse see first?" Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
- Who is the most stable client?
Remember, we're looking for the most stable client in this question, NOT the client who you would see first.
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Evaluation questions. Move to Step 5.
STEP 5: Read each answer choice and use the Who Do You See First rules.
Who Do You See First Rules:
- Is the client stable or unstable? Eliminate the stable clients.
- Is the client experiencing an expected or unexpected finding? Eliminate expected findings.
- Are the remaining answer options referring to airway, breathing, or circulation (ABCs)? Eliminate each non-priority answer option using the ABCs.
- Are the remaining answers options referring to acute or chronic situations? Eliminate the chronic situation answer options.
- Are the remaining answer options real (actual) or potential problems? Eliminate the potential problem answer options.
- Look at each answer option that remains and ask, what outcome do you want for this client?
- Does this answer option make sense in this situation? If yes, keep this answer option.
- Will this answer option help the client? If yes, keep this answer option.
- Will this answer option hurt the client? If yes, eliminate this answer option.
Unstable vs. Stable
1. A client diagnosed with bacterial meningitis and Glasgow Coma Scale of 7. Unstable. This client is in a coma. Eliminate.
2. A client 1 day postoperative after a transsphenoidal craniotomy with a possible cerebrospinal leak. Unstable. The client is at risk of meningitis from the CSF leak, and the client is at risk for diabetes insipidus and increased ICP from the surgical procedure. Eliminate.
3. A client diagnosed with a frontal lobe stroke 4 days ago who is exhibiting confusion. Stable. Confusion is common if a stroke occurs in the frontal lobe of the brain. The nurse should perform a neurological assessment, but there are no other indications that the client is unstable. After 4 days, the risk of this client having a second stroke is significantly reduced. Therefore, the focus of care is rehabilitation. This client can likely be transferred.
4. A client with a head injury who is having seizures. Unstable. A client with a head injury who is experiencing seizures should not be transferred. Seizures after a head injury are frequently caused by increased ICP. Eliminate.
Select the best choice:
Is #3 the correct answer? Yes, this is the most stable client.
Does #3 make sense? Yes, it makes sense to transfer this client to rehabilitation services.
