Level: Advanced
Difficulty: Hard
Subtopic: Crisis intervention
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for acute emotional crisis. Assessment d…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for acute emotional crisis. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale
Correct answer: D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.