Psychiatric / mental health nursing · practice question
A 31-year-old client on an inpatient psychiatric unit is being evaluated for involuntary hold status. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Which assessment approach should the nurse use first?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Why
Assessment begins with stability screening and focused data collection before invasive or delayed actions.
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