Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for agitation on an inpatient psych…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for agitation on an inpatient psychiatric unit. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that pacing aggressively, clenching fists, and refusing to sit.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that pacing aggressively, clenching fists, and refusing to sit.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.