Level: Clinical
Difficulty: Medium
Subtopic: Psychosis
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for auditory hallucinations. Assessment da…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for auditory hallucinations. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Complete nonurgent tasks first because the client appears calm.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: C. 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.