Level: Clinical
Difficulty: Medium
Subtopic: Adolescent development
NCLEX: A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent development. The nurse reviews this trend: oral intake decreased for 2 days while the client reports command hallucinations. Which interpretation and action are most appropriate?
Question
A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.