Level: Foundational
Difficulty: Easy
Subtopic: Anxiety disorders
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for panic symptoms. Assessment data incl…
Psychiatric / mental health nursing Clinical Judgment Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for panic symptoms. Assessment data include the client reports hearing voices telling them to hurt themselves. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.