Level: Advanced
Difficulty: Hard
Subtopic: Grief and coping
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to grief and coping. Assessment data…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A client in an outpatient clinic is being evaluated for nursing care related to grief and coping. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that withdrawn, flat affect, and refusing meals for 2 days.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that withdrawn, flat affect, and refusing meals for 2 days.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that withdrawn, flat affect, and refusing meals for 2 days.
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.