Level: Clinical
Difficulty: Medium
Subtopic: Young adult development
NCLEX: A 24-year-old client in an outpatient clinic is being evaluated for developmental expectations for young adult de…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 24-year-old client in an outpatient clinic is being evaluated for developmental expectations for young adult development. Assessment data include the client reports work stress, poor sleep, and increased alcohol use. 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 the client reports work stress, poor sleep, and increased alcohol use.
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 the client reports work stress, poor sleep, and increased alcohol use.
Rationale
Correct answer: D. The new finding that the client reports work stress, poor sleep, and increased alcohol use.
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.