Level: Advanced
Difficulty: Hard
Subtopic: Grief and coping
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to grief and coping. Assessment data…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A client in an outpatient clinic is being evaluated for nursing care related to grief and coping. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.