Prioritization
A patient says they plan to kill themselves tonight and identifies a specific method. What is the nurse's priority?
Stay with the patient, initiate immediate safety precautions, and urgently notify the clinical team.
A patient taking an antipsychotic develops fever, severe muscle rigidity, confusion, and unstable vital signs. What reaction is possible?
Neuroleptic malignant syndrome (NMS); urgently notify the clinical team and hold further doses pending evaluation.
A patient taking an SSRI wants to stop it abruptly because they feel better. What is the best response?
Encourage them to discuss a planned taper or medication change with the prescriber rather than stopping abruptly on their own.
A patient with diabetes is sweaty, shaky, and confused; glucose is 48 mg/dL and the patient can swallow safely. What should the nurse do?
Give fast-acting oral carbohydrate per protocol and recheck glucose at the specified interval.
A patient with schizophrenia says, 'The voices tell me I am worthless.' What is a therapeutic response?
Acknowledge the distress without validating the hallucination, then ask whether the voices tell them to hurt themselves or anyone else.
A patient reports crushing chest pain, is pale and diaphoretic, and has new shortness of breath. Who should be assessed first?
The patient with chest pain and shortness of breath.
A patient with pneumonia has RR 32/min, SpO2 84% on room air, BP 88/54, and new confusion. What is the priority?
Call emergency/rapid-response support, assess airway and breathing, provide appropriate oxygen support per protocol, and reassess urgently.
A patient asks if IV potassium can be given by IV push to save time. What is the safe response?
No. Potassium chloride must never be administered by IV push; use prescribed dilution and controlled infusion per policy.
A patient with sodium 119 mEq/L is having a seizure. What is the priority?
Protect from injury, support airway/breathing, activate emergency help, and anticipate urgent treatment.
A patient with heart failure develops severe dyspnea, crackles, and pink frothy sputum. What complication is likely?
Acute pulmonary edema.
A patient with schizophrenia is pacing, shouting, and clenching their fists. What is the best initial nursing approach?
Maintain safe distance and exit access, use a calm nonthreatening approach, reduce stimulation, and summon help according to policy.
A patient recently started another serotonergic medication and now has agitation, sweating, diarrhea, tremor, and clonus. What should the nurse suspect?
Serotonin syndrome.
A patient taking clozapine reports fever and sore throat. What should the nurse advise?
Clozapine can cause severe neutropenia; infection symptoms require urgent evaluation.
A patient presents with agitation, sweating, tremor, and confusion. Why is it unsafe to assume this is purely psychiatric?
These signs can reflect hypoglycemia, hypoxia, infection, intoxication, withdrawal, or another acute medical condition; assess medical causes.
A patient with a history of trauma becomes distressed during a procedure and says, 'Stop touching me.' What should the nurse do?
Pause if clinically safe, explain what is happening, ask permission before continuing, and offer choices.
A patient arrives with stridor, another with an ankle sprain, and another with a small laceration. Who is the priority?
The patient with stridor.
A patient with infection develops fever, tachycardia, hypotension, and altered mentation. What complication is concerning?
Sepsis with possible septic shock.
A patient taking an ACE inhibitor develops swelling of the lips and tongue. What should the nurse suspect?
Angioedema; treat as an airway emergency and summon urgent help.
A patient has potassium 6.4 mEq/L. What is the immediate concern?
Potentially life-threatening cardiac dysrhythmias.
A patient with suspected stroke asks for water. What should the nurse do?
Keep the patient NPO until a validated swallow screen/evaluation is completed.
A patient with depression becomes suddenly cheerful after days of hopelessness and says, 'Everything is settled now.' What should the nurse do?
A sudden mood change does not rule out suicide risk and warrants direct assessment.
A patient with depression becomes acutely confused and inattentive over several hours. What should the nurse consider?
Delirium or another acute medical cause, not simply worsening depression.
A patient taking benzodiazepines daily plans to stop suddenly today. What is the key safety concern?
Withdrawal can be dangerous, including seizures; contact the prescriber for a supervised taper plan.
A patient with alcohol withdrawal has a seizure. What is the immediate nursing priority?
Protect the patient from injury, maintain airway and breathing, call for emergency help, and follow seizure/withdrawal protocols.
A patient in a manic episode has slept very little, is intrusive, and attempts unsafe activities. What is a priority intervention?
Reduce stimulation, set calm consistent limits, protect from injury, and support hydration, nutrition, and rest.