Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assess…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.