Level: Foundational
Difficulty: Easy
Subtopic: Shock states
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to shock states. Assessment…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to shock states. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale
Correct answer: D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.