Level: Clinical
Difficulty: Medium
Subtopic: Enteral nutrition
NCLEX: A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to enteral nutrition…
Nutrition Basic Care and Comfort
Case Study
A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to enteral nutrition. Assessment data include the client has potassium 5.9 mEq/L while asking about salt substitutes. Which nurse response best supports psychosocial integrity?
Question
A. False reassurance that nothing is wrong.
B. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
B. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: B. 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.