Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for agitation on an inpatient psych…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for agitation on an inpatient psychiatric unit. Assessment data include the client reports hearing voices telling them to hurt themselves. Which error is most dangerous on the NCLEX and in practice?
Question
A. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: A. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.