Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal assessment
NCLEX: A 49-year-old client in the emergency department is being evaluated for musculoskeletal assessment during hospita…
Health assessment Reduction of Risk Potential
Case Study
A 49-year-old client in the emergency department is being evaluated for musculoskeletal 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. The new finding that tries to get out of bed unassisted and becomes unsteady.
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 tries to get out of bed unassisted and becomes unsteady.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. 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.