Level: Clinical
Difficulty: Medium
Subtopic: Psychosis
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for auditory hallucinations. Assessment da…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for auditory hallucinations. Assessment data include the client reports hearing voices telling them to hurt themselves. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that reports hearing voices telling them to hurt themselves.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that reports hearing voices telling them to hurt themselves.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.