Nursing fundamentals · practice question
A 76-year-old client in a long-term care facility is being evaluated for nursing care related to mobility and positioning. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which finding requires the nurse to intervene immediately?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals
Answer and explanation
Correct answer
D. The new finding that blood pressure 180/102 mm Hg with headache and blurred vision.
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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