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 Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Pain relief before checking airway and breathing.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
B. Pain relief before checking airway and breathing.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: A. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.