Level: Advanced
Difficulty: Hard
Subtopic: Renal impairment
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to renal impairment….
Pathophysiology Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to renal impairment. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which nurse response best supports psychosocial integrity?
Question
A. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
B. False reassurance that nothing is wrong.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
B. False reassurance that nothing is wrong.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: A. 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.