Level: Clinical
Difficulty: Medium
Subtopic: Change management
NCLEX: The nurse manager during a busy day shift is being evaluated for nursing care related to change management. Asses…
Leadership and management Management of Care
Case Study
The nurse manager during a busy day shift is being evaluated for nursing care related to change management. Assessment data include new chest pain rated 8/10 with diaphoresis. 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 new chest pain rated 8/10 with diaphoresis.
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 new chest pain rated 8/10 with diaphoresis.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that new chest pain rated 8/10 with diaphoresis.
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.