Level: Advanced
Difficulty: Hard
Subtopic: Stress response
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to stress response. 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 stress response. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: B. 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.