Level: Foundational
Difficulty: Easy
Subtopic: Neurologic disorders
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for acute stroke symptoms. Assessment data include th…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for acute stroke symptoms. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that reports sudden sharp chest pain and respirations 32/min after surgery.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that reports sudden sharp chest pain and respirations 32/min after surgery.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that reports sudden sharp chest pain and respirations 32/min after surgery.
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.