Level: Foundational
Difficulty: Easy
Subtopic: Neurologic disorders
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for acute stroke symptoms. Assessment data inc…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for acute stroke symptoms. Assessment data include surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which nurse response best supports psychosocial integrity?
Question
A. False reassurance that nothing is wrong.
B. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
B. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: B. 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.