Psychology / lifespan development · practice question

A client in an outpatient clinic is being evaluated for nursing care related to stress response. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which nursing action should the nurse take first?

Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026psychology-lifespan-development

Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Administer the next scheduled intervention before reassessing 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 client in an outpatient clinic is being evaluated for nursing care related to stress response. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which nursing action should the nurse take first?

Correct answer

Why

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