Psychiatric / mental health nursing · practice question
A 42-year-old client in a crisis stabilization unit is being evaluated for agitation on an inpatient psychiatric unit. Assessment data include the client reports hearing voices telling them to hurt themselves. Which nursing action should the nurse take first?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026psychiatric-mental-health
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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