Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for agitation on an inpatient psychiatric…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for agitation on an inpatient psychiatric unit. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.