Level: Clinical
Difficulty: Medium
Subtopic: Trauma-informed care
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for history of intimate partner vio…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for history of intimate partner violence. The nurse reviews this trend: suicide risk screening changed from passive thoughts to a plan with access to means. Which interpretation and action are most appropriate?
Question
A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.