Nursing fundamentals · practice question

A 76-year-old client in a long-term care facility is being evaluated for nursing care related to documentation fundamentals. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which finding requires the nurse to intervene immediately?

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

A comfort request with unchanged vital signs and no new symptoms.Routine data unchanged from the prior assessment.A stable, long-standing finding that matches the expected care plan.The new finding that tries to get out of bed unassisted and becomes unsteady.

Answer and explanation

Correct answer

D. The new finding that tries to get out of bed unassisted and becomes unsteady.

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 nursing care related to documentation fundamentals. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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