Level: Clinical
Difficulty: Medium
Subtopic: Middle adult development
NCLEX: A 48-year-old client at an annual wellness visit is being evaluated for developmental expectations for middle adu…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 48-year-old client at an annual wellness visit is being evaluated for developmental expectations for middle adult development. Assessment data include blood pressure screening is 168/96 mm Hg at two visits. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that blood pressure screening is 168/96 mm Hg at two visits.
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 blood pressure screening is 168/96 mm Hg at two visits.
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.