Level: Foundational
Difficulty: Easy
Subtopic: Anxiety disorders
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for panic symptoms. Assessment data…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for panic symptoms. Assessment data include the client reports hearing voices telling them to hurt themselves. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Administer the next scheduled intervention before reassessing the client.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.