Level: Foundational
Difficulty: Easy
Subtopic: Anxiety disorders
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for panic symptoms. Assessment data…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for panic symptoms. 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. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that states, "I don't want to live anymore" and has a plan with access to means.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that states, "I don't want to live anymore" and has a plan with access to means.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. 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.