Level: Clinical
Difficulty: Medium
Subtopic: Generate solutions
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to generate solution…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for nursing care related to generate solutions. Assessment data include the client improves after the initial intervention but develops a new safety concern. 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.