Level: Clinical
Difficulty: Medium
Subtopic: Adolescent development
NCLEX: A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent development. Assessment data include the adolescent asks whether the visit can remain confidential. 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.