Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for high fall risk on a medical unit. Assess…
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 high fall risk on a medical unit. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Using the clinical judgment model, what is the nurse's first step?
Question
A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: A. 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.