A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?

"I've never been the kind of person to ask others for help."

"I'm looking forward to being able to be independent again."

"I really don't know what I'm supposed to do all day."

"It's nice having other people cook for me."

Answer and Explanation

The Correct Answer is D

A. "I've never been the kind of person to ask others for help":

This statement indicates that the client may still be struggling with accepting help from others, which suggests that they have not fully adapted to their new situational role. It reflects a reluctance to rely on others and may indicate a desire to maintain independence.

B. "I'm looking forward to being able to be independent again":

While this statement suggests a desire for independence, it does not necessarily indicate that the client has already adapted to their new situational role. It may reflect an aspiration or goal rather than a current state of adaptation.

C. "I really don't know what I'm supposed to do all day":

This statement suggests uncertainty and confusion about how to fill the day, which may indicate difficulty adjusting to the new living arrangement and role. It does not necessarily indicate adaptation but rather a sense of disorientation or discomfort with the current situation.

D. "It's nice having other people cook for me."

This statement suggests that the client has become comfortable with and is accepting of the support provided by their adult child, indicating an adaptation to their new situational role. By expressing appreciation for having others cook for them, the client demonstrates a willingness to rely on and accept assistance from their family member, which is an important aspect of adapting to changes in living arrangements and roles.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Apply the pouch while the skin barrier is still damp.

Applying the pouch while the skin barrier is damp can lead to poor adhesion and potential leaks. It’s essential to ensure the skin is completely dry before attaching the pouch.

B. Change the pouch once every 24 hr.: The frequency of pouch changes depends on individual client needs, stoma output, and the type of pouching system used. Changing the pouch every 24 hours may be unnecessary for some clients and could potentially cause skin irritation or damage.

C. Rub the peristomal skin dry after cleaning: Rubbing the peristomal skin dry after cleaning can cause irritation and damage to the skin. Instead, the nurse should gently pat the skin dry using a soft cloth or towel to avoid causing friction or trauma to the delicate skin surrounding the stoma.

D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma:a allows for a better fit and helps prevent the edges of the stoma from coming into contact with stool, which can cause irritation and breakdown of the skin. A proper fit also helps ensure a secure seal and prevents leakage.

A. Use a trochanter roll. B. Use foot splints. C. Apply an abduction pillow to the legs. D. Prop the feet up

Correct Answer is B

Explanation

A. Use a trochanter roll:

A trochanter roll is a positioning device placed alongside the hip to prevent external rotation of the hip joint and maintain proper alignment of the lower extremities. While it is important for maintaining proper hip alignment, it does not specifically address preventing plantar flexion contractures.

B. Use foot splints.

Plantar flexion contractures occur when the muscles and tendons in the foot and ankle become shortened, leading to a fixed downward pointing of the foot. Foot splints are devices designed to maintain the foot in a neutral position, preventing the development of contractures by keeping the ankle dorsiflexed. They help stretch the muscles and tendons in the foot and ankle, preventing them from becoming shortened over time.

C. Apply an abduction pillow to the legs:

An abduction pillow is a positioning device used to maintain proper hip alignment and prevent adduction of the hips and knees. While it is essential for preventing hip contractures and maintaining hip alignment, it does not directly address preventing plantar flexion contractures.

D. Prop the feet up:

Elevating the feet may be beneficial for improving circulation and reducing swelling, but it does not specifically address preventing plantar flexion contractures. In fact, prolonged elevation of the feet without proper support may increase the risk of developing contractures by allowing the foot to remain in a plantar flexed position for extended periods.

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A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?

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