Level: Foundational
Difficulty: Easy
Subtopic: Confidentiality and HIPAA
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to confidentiality an…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to confidentiality and hipaa. Assessment data include UAP reports the client fell in the bathroom. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that UAP reports the client fell in the bathroom.
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 UAP reports the client fell in the bathroom.
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.