Level: Advanced
Difficulty: Hard
Subtopic: Stress response
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to stress response. Assessment data…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A client in an outpatient clinic is being evaluated for nursing care related to stress response. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: B. 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.