Level: Foundational
Difficulty: Easy
Subtopic: Electrolyte charge and movement
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to electrolyte charge…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to electrolyte charge and movement. Assessment data include the client develops redness and warmth at an IV insertion site. 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.