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 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.