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 has not slept in 3 days and speech is rapid and pressured. Which error is most dangerous on the NCLEX and in practice?
Question
A. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: A. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.