Level: Advanced
Difficulty: Hard
Subtopic: Focused reassessment
NCLEX: A 49-year-old client in the emergency department is being evaluated for focused reassessment during hospitalizati…
Health assessment Reduction of Risk Potential
Case Study
A 49-year-old client in the emergency department is being evaluated for focused reassessment 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. 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.