The nurse is caring for a client diagnosed with septic shock. Which finding would lead the nurse to suspect the client is developing disseminated intravascular coagulation (DIC)?

A. While looking for tattooing or 'branding' markscan provide evidence of abuse, it is not the first action. This is part of a physical assessment, which should follow establishing safety and rapport with the client.

B. Completing a full psychosocial assessmentis important, but first the nurse must ensure the client is in a safe environmentto disclose sensitive information. A comprehensive assessment can be conducted after addressing immediate safety concerns.

C. The priority is to assess for safety and potential abuse. Asking a direct, nonjudgmental question like, "Does anyone you know make you feel unsafe?"allows the client an opportunity to disclose abuse in a safe and private setting. Safety is always the first priority when domestic or intimate partner violence is suspected.

D. Following agency policy for reportingis important, but it is not the first action. Nurses must first assess the situation and confirm immediate safety needsbefore initiating reports. Immediate reporting without client disclosure or context may not address urgent safety concerns.

A. In an unconscious patient, airway and breathing take priorityaccording to the ABC (Airway, Breathing, Circulation) approachin emergency care. Even if the patient is breathing spontaneously, the nurse must assess for adequate oxygenation, airway patency, and signs of respiratory compromisebefore addressing other interventions. Immediate identification of airway obstruction or inadequate breathing can be life-saving.

B. Incorrect as the first action. While IV access is important for fluid resuscitation or medication administration, it does not take priority over ensuring airway and effective breathing, which are immediately life-sustaining.

C. Incorrect as the first action. A full physical assessment is important for identifying injuries, but airway and breathing must be addressed first. Removing clothing can occur after the patient is stabilized.

D. Incorrect as the first action. Assessing LOC is important to monitor neurological status, but it does not take priority over ensuring the patient can maintain adequate ventilation and oxygenation. LOC assessment can be done simultaneously or immediately after securing airway and breathing.