Level: Foundational
Difficulty: Easy
Subtopic: Inflammation and cellular injury
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to inflammation and c…
Pathophysiology Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to inflammation and cellular injury. Assessment data include bilateral calf pain with redness and warmth after bedrest. Which nurse response best supports psychosocial integrity?
Question
A. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
B. False reassurance that nothing is wrong.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
B. False reassurance that nothing is wrong.
C. Changing the subject when the client expresses fear.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: A. 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.