Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for agitation on an inpatient psychiatric…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for agitation on an inpatient psychiatric unit. The nurse reviews this trend: sleep decreased to 2 hours per night with pressured speech and impulsive behavior. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.