Level: Foundational
Difficulty: Easy
Subtopic: Suicide risk
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for expressions of hopelessness. Assessmen…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for expressions of hopelessness. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that states, "I don't want to live anymore" and has a plan with access to means.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that states, "I don't want to live anymore" and has a plan with access to means.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that states, "I don't want to live anymore" and has a plan with access to means.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.