Level: Foundational
Difficulty: Easy
Subtopic: Therapeutic communication
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for anxiety about hospitalization. Asses…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for anxiety about hospitalization. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that has not slept in 3 days and speech is rapid and pressured.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that has not slept in 3 days and speech is rapid and pressured.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.