Level: Foundational
Difficulty: Easy
Subtopic: Homeostasis and feedback loops
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to homeostasis and feedback…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to homeostasis and feedback loops. Assessment data include client appears anxious and asks for help understanding the care plan. 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 client appears anxious and asks for help understanding the care plan.
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 client appears anxious and asks for help understanding the 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: B. The new finding that client appears anxious and asks for help understanding the care plan.
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.