Level: Clinical
Difficulty: Medium
Subtopic: Skin integrity
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to skin integrity….
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 nursing care related to skin integrity. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. 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.