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 is pacing aggressively, clenching fists, and refusing to sit. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
Rationale
Correct answer: C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.