Level: Foundational
Difficulty: Easy
Subtopic: Vital signs
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for postoperative monitoring. Assessment dat…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 70-year-old client in a rehabilitation facility is being evaluated for postoperative monitoring. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which nurse response best supports psychosocial integrity?
Question
A. False reassurance that nothing is wrong.
B. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
B. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: B. 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.