Level: Foundational
Difficulty: Easy
Subtopic: Gastrointestinal disorders
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for partial bowel obstruction. Assessment data…
Adult health / medical-surgical nursing Clinical Judgment Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for partial bowel obstruction. Assessment data include sudden slurred speech and right-sided weakness began 30 minutes ago. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.