Level: Clinical
Difficulty: Medium
Subtopic: Enzymes and metabolic pathways
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to enzymes and metabo…
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 enzymes and metabolic pathways. Assessment data include a family member reports the client seems confused since this morning. 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.