Level: Advanced
Difficulty: Hard
Subtopic: Grief and coping
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to grief and coping. The nurse revie…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A client in an outpatient clinic is being evaluated for nursing care related to grief and coping. The nurse reviews this trend: oral intake decreased for 2 days while the client reports command hallucinations. Which interpretation and action are most appropriate?
Question
A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.