A nurse is assessing an adolescent client whose parent has recently died.
Which of the following findings should the nurse expect?

Choice A rationale:

Kohlberg's theory of moral development includes several stages, and in the stage of the social contract, individuals begin to challenge rules and laws that they believe infringe upon the rights of others. This stage is characterized by the development of a sense of justice and social responsibility. Individuals in this stage may question laws and rules that they see as unjust and work towards changing them in favor of the greater good.

Choice B rationale:

Law and order is a stage in Kohlberg's theory where individuals prioritize following the established laws and rules of society. They may not necessarily challenge these rules, as their primary concern is maintaining order and obedience to authority.

Choice C rationale:

Punishment and obedience is one of the earlier stages in Kohlberg's theory, where individuals focus on avoiding punishment and obeying authority figures. This stage does not involve challenging rules for the sake of protecting the rights of others.

Choice D rationale:

Good boy-nice girl is a stage where individuals seek approval and avoid disapproval from others. They tend to conform to societal expectations and do not necessarily challenge rules that may impinge on the rights of others.

Choice A rationale:

The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.

Choice B rationale:

The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.

Choice C rationale:

The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.

Choice D rationale:

The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.