Level: Clinical
Difficulty: Medium
Subtopic: Substance use disorders
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for alcohol withdrawal risk. Assess…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for alcohol withdrawal risk. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. 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. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale
Correct answer: D. 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.