Psychiatric / mental health nursing · practice question
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for history of intimate partner violence. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which nursing action should the nurse take first?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Why
First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
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