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 is pacing aggressively, clenching fists, and refusing to sit. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Choosing an intervention before identifying assessment cues and immediate safety risk.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Choosing an intervention before identifying assessment cues and immediate safety risk.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: B. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.