Level: Advanced
Difficulty: Hard
Subtopic: Medication reconciliation
NCLEX: A 72-year-old client in a long-term care facility is being evaluated for transfer from another facility with mult…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 72-year-old client in a long-term care facility is being evaluated for transfer from another facility with multiple home medications. Assessment data include blood glucose 54 mg/dL with diaphoresis and confusion. Which nurse response best supports psychosocial integrity?
Question
A. False reassurance that nothing is wrong.
B. Changing the subject when the client expresses fear.
C. Promising outcomes that cannot be guaranteed.
D. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
B. Changing the subject when the client expresses fear.
C. Promising outcomes that cannot be guaranteed.
D. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
Rationale
Correct answer: D. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
Rationale: Psychosocial integrity items reward therapeutic communication and appropriate safety screening, not avoidance or false promises.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Psychosocial integrity items reward therapeutic communication and appropriate safety screening, not avoidance or false promises.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.