Nursing fundamentals · practice question

A 70-year-old client in a rehabilitation facility is being evaluated for high fall risk on a medical unit. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nurse response best supports psychosocial integrity?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals

Promising outcomes that cannot be guaranteed.Changing the subject when the client expresses fear.False reassurance that nothing is wrong.Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.

Answer and explanation

Correct answer

D. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.

Why

Psychosocial integrity items reward therapeutic communication and appropriate safety screening, not avoidance or false promises.

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A 70-year-old client in a rehabilitation facility is being evaluated for high fall risk on a medical unit. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nurse response best supports psychosocial integrity?

Correct answer

Why

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