Level: Foundational
Difficulty: Easy
Subtopic: Cardiac conduction and perfusion
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to cardiac conduction and pe…
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 cardiac conduction and perfusion. Assessment data include pain increases from 3/10 to 8/10 over 30 minutes. 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 pain increases from 3/10 to 8/10 over 30 minutes.
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 pain increases from 3/10 to 8/10 over 30 minutes.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that pain increases from 3/10 to 8/10 over 30 minutes.
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.