Level: Clinical
Difficulty: Medium
Subtopic: Trauma-informed care
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for history of intimate partner violence…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for history of intimate partner violence. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.