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Nursing fundamentals · practice question

A 76-year-old client in a long-term care facility is being evaluated for nursing care related to hygiene and comfort. Assessment data include the client reports no sleep and increasing agitation overnight. Which finding requires the nurse to intervene immediately?

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Answer and explanation

Correct answer

A. The new finding that reports no sleep and increasing agitation overnight.

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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