Psychiatric / mental health nursing · practice question

A 42-year-old client in a crisis stabilization unit is being evaluated for alcohol withdrawal risk. Assessment data include the client reports hearing voices telling them to hurt themselves. Which nursing action should the nurse take first?

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

Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Tell the client symptoms are expected and avoid notifying the health care team.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.

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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A 42-year-old client in a crisis stabilization unit is being evaluated for alcohol withdrawal risk. Assessment data include the client reports hearing voices telling them to hurt themselves. Which nursing action should the nurse take first?

Correct answer

Why

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