Level: Clinical
Difficulty: Medium
Subtopic: Respiratory assessment
NCLEX: A 49-year-old client in the emergency department is being evaluated for respiratory assessment during hospitaliza…
Health assessment Reduction of Risk Potential
Case Study
A 49-year-old client in the emergency department is being evaluated for respiratory assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. 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. Routine data unchanged from the prior assessment.
D. The new finding that tries to get out of bed unassisted and becomes unsteady.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that tries to get out of bed unassisted and becomes unsteady.
Rationale
Correct answer: D. The new finding that tries to get out of bed unassisted and becomes unsteady.
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.