Level: Foundational
Difficulty: Easy
Subtopic: Suicide risk
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessm…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. 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. Give a blanket answer that everything is fine and continue the prior plan.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.