Psychiatric / mental health nursing · practice question

A 42-year-old client in a crisis stabilization unit is being evaluated for acute emotional crisis. Assessment data include the client reports hearing voices telling them to hurt themselves. Which finding requires the nurse to intervene immediately?

Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health

The new finding that reports hearing voices telling them to hurt themselves.A comfort request with unchanged vital signs and no new symptoms.A stable, long-standing finding that matches the expected care plan.Routine data unchanged from the prior assessment.

Answer and explanation

Correct answer

A. The new finding that reports hearing voices telling them to hurt themselves.

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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A 42-year-old client in a crisis stabilization unit is being evaluated for acute emotional crisis. Assessment data include the client reports hearing voices telling them to hurt themselves. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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