Level: Clinical
Difficulty: Medium
Subtopic: Older adult changes
NCLEX: A 78-year-old client in a long-term care facility is being evaluated for nursing care related to older adult chan…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 78-year-old client in a long-term care facility is being evaluated for nursing care related to older adult changes. Assessment data include the caregiver reports new confusion since yesterday morning. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that the caregiver reports new confusion since yesterday morning.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that the caregiver reports new confusion since yesterday morning.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that the caregiver reports new confusion since yesterday morning.
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.