Level: Foundational
Difficulty: Easy
Subtopic: Suicide risk
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessm…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.