Level: Advanced
Difficulty: Hard
Subtopic: Environmental health
NCLEX: The home health nurse during an initial home visit is being evaluated for community health nursing and environmen…
Community / public health nursing Health Promotion and Maintenance
Case Study
The home health nurse during an initial home visit is being evaluated for community health nursing and environmental health. Assessment data include vaccination records show several children are overdue for required immunizations. 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 vaccination records show several children are overdue for required immunizations.
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 vaccination records show several children are overdue for required immunizations.
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 vaccination records show several children are overdue for required immunizations.
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.