Level: Clinical
Difficulty: Medium
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 is pacing aggressively, clenching fists, and refusing to sit. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: B. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.