Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: A 55-year-old client after abdominal surgery is being evaluated for high fall risk on a medical unit. Assessment…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 55-year-old client after abdominal surgery is being evaluated for high fall risk on a medical unit. Assessment data include pain 9/10 and guards the abdomen after surgery. The nurse is evaluating discharge teaching. Which client statement shows correct understanding?
Question
A. "I will stop my medications when I feel better."
B. "I do not need to report mild symptoms unless they become unbearable."
C. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
D. "The nurse does not need to know about changes unless the provider asks."
B. "I do not need to report mild symptoms unless they become unbearable."
C. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
D. "The nurse does not need to know about changes unless the provider asks."
Rationale
Correct answer: C. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.