Level: Advanced
Difficulty: Hard
Subtopic: Crisis intervention
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for acute emotional crisis. Assessment dat…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for acute emotional crisis. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.