Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalizat…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that has not voided in 8 hours and lower abdomen is firm and tender.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that has not voided in 8 hours and lower abdomen is firm and tender.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that has not voided in 8 hours and lower abdomen is firm and tender.
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.