Level: Clinical
Difficulty: Medium
Subtopic: Parenteral nutrition
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to parenteral nutriti…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to parenteral nutrition. Assessment data include the client receives enteral feeding and develops abdominal distention with nausea. 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.