Psychosocial Integrity Practice Question

Question

The nurse is caring for a client with panic symptoms and is focused on substance withdrawal scenario 11. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
3. C. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
4. D. Monitor safety and physiologic instability while using ordered protocols.

Correct Answer

D. Monitor safety and physiologic instability while using ordered protocols.

Explanation

The priority action for substance withdrawal is to monitor safety and physiologic instability while using ordered protocols. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: hard
• Domain: Psychosocial Integrity
• Objective: substance withdrawal

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