Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for agitation on an inpatient psychiatri…
Psychiatric / mental health nursing Clinical Judgment Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for agitation on an inpatient psychiatric unit. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Using the clinical judgment model, what is the nurse's first step?
Question
A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.