Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for pneumonia with increased work of breathing…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for pneumonia with increased work of breathing. Assessment data include the client reports worst headache of life with neck stiffness. 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.