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 Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Administer the next scheduled intervention before reassessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.