Level: Clinical
Difficulty: Medium
Subtopic: Neurologic control and level of consciousness
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to neurologic control…
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 neurologic control and level of consciousness. Assessment data include the nurse notes an unexpected finding during routine assessment. 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.