Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for agitation on an inpatient psychiatri…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for agitation on an inpatient psychiatric unit. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. 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.