Level: Clinical
Difficulty: Medium
Subtopic: Clotting and bleeding disorders
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for clotting and bleeding disorder. Assessment…
Pathophysiology Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for clotting and bleeding disorder. Assessment data include the client reports worst headache of life with neck stiffness. 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. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
D. Promising outcomes that cannot be guaranteed.
B. Changing the subject when the client expresses fear.
C. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: C. 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.