Level: Advanced
Difficulty: Hard
Subtopic: Vaccination and herd protection
NCLEX: A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to vaccination and he…
Microbiology Safety and Infection Prevention and Control
Case Study
A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to vaccination and herd protection. Assessment data include wound culture grows MRSA with spreading erythema. 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.