Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal structure and mobility
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to musculoskeletal structure…
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 musculoskeletal structure and mobility. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected 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: A. The new finding that vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min.
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.