Level: Foundational
Difficulty: Easy
Subtopic: Recognize cues
NCLEX: An RN prioritizing care after a change in status is being evaluated for unfolding changes in a case study. Assess…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for unfolding changes in a case study. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. The nurse is evaluating discharge teaching. Which client statement shows correct understanding?
Question
A. "I will stop my medications when I feel better."
B. "I do not need to report mild symptoms unless they become unbearable."
C. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
D. "The nurse does not need to know about changes unless the provider asks."
B. "I do not need to report mild symptoms unless they become unbearable."
C. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
D. "The nurse does not need to know about changes unless the provider asks."
Rationale
Correct answer: C. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.