Level: Foundational
Difficulty: Easy
Subtopic: Mobility and positioning
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to mobility and pos…
Nursing fundamentals Basic Care and Comfort Clinical Judgment Safety and Infection Prevention and Control
Case Study
A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to mobility and positioning. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Evaluate discharge readiness before addressing acute findings.
C. Document the assessment at the end of the shift and continue the prior plan.
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Evaluate discharge readiness before addressing acute findings.
C. Document the assessment at the end of the shift and continue the prior plan.
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale
Correct answer: D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.