Nursing fundamentals · practice question

A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Which finding requires the nurse to intervene immediately?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals

A comfort request with unchanged vital signs and no new symptoms.The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.Routine data unchanged from the prior assessment.A stable, long-standing finding that matches the expected care plan.

Answer and explanation

Correct answer

B. The new finding that pressure injury stage 2 noted on the coccyx with unchanged dressing.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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