Level: Advanced
Difficulty: Hard
Subtopic: Head and neck assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for head and neck assessment during hospitalizati…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for head and neck assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. 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.