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 pacing aggressively, clenching fists, and refusing to sit. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.