Level: Advanced
Difficulty: Hard
Subtopic: Oxidation and cellular energy
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to oxidation and cell…
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 oxidation and cellular energy. Assessment data include the client refuses a recommended intervention and requests another option. 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. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
D. Promising outcomes that cannot be guaranteed.
B. Changing the subject when the client expresses fear.
C. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: C. 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.