Level: Foundational
Difficulty: Easy
Subtopic: Therapeutic communication
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for anxiety about hospitalization. Assessm…
Psychiatric / mental health nursing Clinical Judgment Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for anxiety about hospitalization. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. 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.