Psychiatric / mental health nursing · practice question
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for panic symptoms. Assessment data include the client reports hearing voices telling them to hurt themselves. Which action should the nurse take first?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Why
NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
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