Level: Foundational
Difficulty: Easy
Subtopic: Mobility and positioning
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to mobility and pos…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for nursing care related to mobility and positioning. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. 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 blood pressure 180/102 mm Hg with headache and blurred vision.
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 blood pressure 180/102 mm Hg with headache and blurred vision.
Rationale
Correct answer: D. The new finding that blood pressure 180/102 mm Hg with headache and blurred vision.
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.