Level: Foundational
Difficulty: Easy
Subtopic: Therapeutic communication
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for anxiety about hospitalization….
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for anxiety about hospitalization. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.