Level: Clinical
Difficulty: Medium
Subtopic: Elimination
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to elimination. Ass…
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 nursing care related to elimination. Assessment data include the client reports no sleep and increasing agitation overnight. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that reports no sleep and increasing agitation overnight.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that reports no sleep and increasing agitation overnight.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that reports no sleep and increasing agitation overnight.
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.