Level: Advanced
Difficulty: Hard
Subtopic: Head and neck assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for head and neck assessment during hospitaliz…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for head and neck assessment during hospitalization. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. 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. Routine data unchanged from the prior assessment.
D. The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.
Rationale
Correct answer: D. The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.
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.