Escalation of new confusion

NCLEX-RN
Management of Care
Bow-tie
Difficulty 3 of 5

Question

Complete the diagram by choosing the condition the client is most likely experiencing, 2 actions to take and 2 parameters to monitor.

Actions to takeSelect 2

Activate emergency assistance per clinic policy✓ Correct
Alert the provider to the new change✓ Correct
Delay action until the next appointment✗ Incorrect
Ask the client to wait alone in the lobby✗ Incorrect

Condition most likely experiencingSelect 1

Acute change requiring emergency assistance✓ Correct
The client’s established baseline✗ Incorrect
A planned routine follow-up✗ Incorrect
A stable communication preference✗ Incorrect

Parameters to monitorSelect 2

Responsiveness✓ Correct
Breathing✓ Correct
Choice of reading material✗ Incorrect
Preference for appointment time✗ Incorrect

Answer

Actions to take: Activate emergency assistance per clinic policy; Alert the provider to the new change · Condition most likely experiencing: Acute change requiring emergency assistance · Parameters to monitor: Responsiveness; Breathing

Rationale

A sudden departure from the client’s usual mental status calls for immediate help. Communicate the change and follow awareness and breathing while emergency care is initiated.

RememberTreat sudden confusion as an urgent change from baseline.

Sources

Sources marked “Adapted from” are licensed under CC BY 4.0. We changed the material: its facts are rewritten into an original question, answer options and rationale. The original authors and publishers do not endorse SwipeExam.

Adapted from Open RN Nursing Skills, 2nd edition: Chapter 1 General Survey Open RN (Chippewa Valley Technical College) · License: CC BY 4.0 · Retrieved November 2, 2026 · BASIC CONCEPTS › Primary Survey · 2nd edition, 2023
Adapted from Open RN Nursing: Mental Health and Community Concepts, 2nd edition: APPLICATION OF THE NURSING PROCESS TO MENTAL HEALTH CARE Open RN (Chippewa Valley Technical College) · License: CC BY 4.0 · Retrieved November 2, 2026 · Mental Status Examination › Signs of Distress · 2nd edition, 2025

Last verified: November 4, 2026 2 independent automated checks Question rn-mc-02475, version 1

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