Level: Foundational
Difficulty: Easy
Subtopic: Mood disorders
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for major depressive symptoms. Assessment…
Psychiatric / mental health nursing Clinical Judgment Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for major depressive symptoms. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. 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. Document the assessment at the end of the shift and continue the prior plan.
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Evaluate discharge readiness before addressing acute findings.
C. Document the assessment at the end of the shift and continue the prior plan.
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale
Correct answer: D. 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.