Psychiatric / mental health nursing · practice question

A 42-year-old client in a crisis stabilization unit is being evaluated for history of intimate partner violence. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Using the clinical judgment model, what is the nurse's first step?

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

Implement the first intervention on the existing care plan without reviewing new data.Document the assessment at the end of the shift and continue the prior plan.Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.Evaluate discharge readiness before addressing acute findings.

Answer and explanation

Correct answer

C. 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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A 42-year-old client in a crisis stabilization unit is being evaluated for history of intimate partner violence. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Using the clinical judgment model, what is the nurse's first step?

Correct answer

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