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 pacing aggressively, clenching fists, and refusing to sit. Which nursing action is the priority to keep the client safe?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Why
Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
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