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 A

Explanation

A. Use trochanter rolls beside the client's legs.

Trochanter rolls are supportive devices placed alongside the client's hips and thighs to prevent external rotation of the hips and maintain proper alignment of the legs. They help prevent hip abduction and rotation, which can lead to hip dislocation or pressure injuries, especially in immobile clients. Therefore, using trochanter rolls is essential in the care of immobile clients to maintain proper alignment and prevent complications.

B. Place the client's arms at their side when turning them: Placing the client's arms at their side during turning may limit movement and comfort. Instead, the nurse should support the client's arms in a position that promotes comfort and maintains proper alignment.

C. Cross the client's ankles when lying supine: Crossing the client's ankles can lead to compromised circulation and pressure on the bony prominences of the ankles, increasing the risk of pressure injuries. It is not recommended to cross the client's ankles in the supine position.

D. Logroll the client every 4 hr: Logrolling is a technique used to move clients with suspected spinal cord injuries while maintaining spinal alignment. However, it is not necessary to logroll an immobile client every 4 hours unless there are specific indications, such as suspicion of a spinal injury. Frequent repositioning, including the use of trochanter rolls, is essential to prevent pressure injuries and maintain skin integrity but should be individualized based on the client's needs and condition.

A. Cut a 4 inch x 4 inch (10 cm x 10 cm) gauze pad to place under the flanges of the tracheostomy tube. B. Cleanse the skin around the stoma with full-strength hydrogen peroxide. C. Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. D. Wear clean gloves while cleaning the inner cannula.

Correct Answer is C

Explanation

A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.

B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.

C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.

D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.

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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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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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