Level: Foundational
Difficulty: Easy
Subtopic: Vitamins and minerals
NCLEX: A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to vitamins and mine…
Nutrition Basic Care and Comfort
Case Study
A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to vitamins and minerals. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. 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.