Psychiatric / mental health nursing · practice question
A 42-year-old client in a crisis stabilization unit is being evaluated for involuntary hold status. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Using the clinical judgment model, what is the nurse's first step?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
Answer and explanation
Correct answer
A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Why
NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
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