Level: Clinical
Difficulty: Medium
Subtopic: Mobility and positioning
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to mobility and pos…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to mobility and positioning. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. 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.