Psychiatric / mental health nursing · practice question
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for alcohol withdrawal risk. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which finding requires the nurse to intervene immediately?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
A. The new finding that pacing aggressively, clenching fists, and refusing to sit.
Why
Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
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