Level: Advanced
Difficulty: Hard
Subtopic: Neurologic injury
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to neurologic injury. Assess…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to neurologic injury. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. 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 crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath.
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 crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath.
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 crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath.
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.