Level: Clinical
Difficulty: Medium
Subtopic: Trauma-informed care
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for history of intimate partner vio…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for history of intimate partner violence. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.