Level: Advanced
Difficulty: Hard
Subtopic: Renal and cardiac diet patterns
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to renal and cardiac…
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 renal and cardiac diet patterns. 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. 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.