Level: Foundational
Difficulty: Easy
Subtopic: Mood disorders
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for major depressive symptoms. Assessmen…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for major depressive symptoms. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale
Correct answer: D. 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.