Level: Advanced
Difficulty: Hard
Subtopic: Stress response
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to stress response. 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 stress response. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. 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. Routine data unchanged from the prior assessment.
D. The new finding that has not slept in 3 days and speech is rapid and pressured.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that has not slept in 3 days and speech is rapid and pressured.
Rationale
Correct answer: D. The new finding that has not slept in 3 days and speech is rapid and pressured.
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.