Level: Clinical
Difficulty: Medium
Subtopic: Disaster preparedness
NCLEX: The community health nurse at a public health clinic is being evaluated for community health nursing and disaster…
Community / public health nursing Health Promotion and Maintenance
Case Study
The community health nurse at a public health clinic is being evaluated for community health nursing and disaster preparedness. Assessment data include a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg.
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.