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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Correct Answer is D

Explanation

A. Extend the client's neck while securing the ties: This action can compromise the client's airway and is not recommended during tracheostomy tie changes. The client's neck should be in a comfortable, neutral position during the procedure.

B. Use a quick-release knot to secure the ties: Quick-release knots are not typically used for securing tracheostomy ties. Instead, a secure knot that can be easily tied and untied is preferred to ensure the stability of the tracheostomy tube.

C. Allow space for three fingers under the ties when securing.

Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.

D. When changing tracheostomy ties, it is essential to maintain airway security and prevent accidental dislodgement of the tracheostomy tube. The nurse should secure the new ties first before removing the old ones to ensure the tracheostomy remains stable.

A. Corneas with an opaque appearance B. Pupils that are 8 to 9 mm in diameter C. Eyelashes that curl slightly outward. D. Eyelids that blink involuntarily 30 to 35 times per minute

Correct Answer is C

Explanation

A. Corneas with an opaque appearance:

An opaque appearance of the corneas indicates an abnormal finding and could suggest a pathological condition such as corneal edema, scarring, or infection. The corneas should normally be clear and transparent to allow light to pass through to the retina.

B. Pupils that are 8 to 9 mm in diameter:

Pupils that are 8 to 9 mm in diameter are abnormally large and dilated. Normal pupil size varies between approximately 2 to 4 mm in diameter under normal lighting conditions. An 8 to 9 mm diameter suggests mydriasis, which may be caused by various factors such as medications, neurological conditions, or trauma.

C. Eyelashes that curl slightly outward.

Eyelashes that curl slightly outward are a normal finding and help to protect the eyes by preventing foreign particles from entering. This finding is considered within the range of normal anatomy and physiology of the eye.

D. Eyelids that blink involuntarily 30 to 35 times per minute:

While blinking is a normal physiological response that helps to keep the surface of the eye moist and clear debris, the rate of involuntary blinking typically ranges from 15 to 20 times per minute in adults, not 30 to 35 times per minute. A higher rate of blinking could indicate irritation, dryness, or other ocular discomfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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