Level: Foundational
Difficulty: Easy
Subtopic: Respiratory gas exchange
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to respiratory gas ex…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to respiratory gas exchange. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. 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. Promising outcomes that cannot be guaranteed.
D. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
B. Changing the subject when the client expresses fear.
C. Promising outcomes that cannot be guaranteed.
D. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
Rationale
Correct answer: D. 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.