Psychiatric / mental health nursing · practice question
A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which nursing action should the nurse take first?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
A. 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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