Level: Foundational
Difficulty: Easy
Subtopic: Anxiety disorders
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for panic symptoms. Assessment data includ…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for panic symptoms. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.