A nurse is presenting to a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

A. The client is attempting to remove the restraint: While this may indicate discomfort or agitation, it does not necessarily warrant loosening the restraint. The nurse should assess the underlying reasons for the client's behavior but may need to keep the restraint in place for safety if the client poses a risk to themselves or others.

B. The client has full range of motion in her wrist: Having full range of motion does not indicate a need to loosen the restraint. The primary concern with restraints is ensuring the client's safety and comfort while monitoring for signs of circulation and proper function.

C. The client's hand is cool and pale: This finding is concerning and indicates potential impaired circulation due to the restraint being too tight. Loosening the restraint is essential in this case to restore circulation and prevent further complications. Coolness and paleness are signs of inadequate blood flow and require immediate action to ensure the client’s safety.

D. The client has a capillary refill of less than 2 seconds: A capillary refill of less than 2 seconds typically indicates good circulation. While monitoring capillary refill is important, this finding alone does not warrant loosening the restraint. The priority is to respond to any indications of compromised circulation.

A. "After breakfast we can review the instructions for insulin self-injection again.": This statement indicates ongoing interaction and teaching with the client, suggesting that the nurse is still in the working phase of the nurse-client relationship rather than the termination phase.

B. "As soon as I get your admission papers I'll be in to talk with you about your health problem.": This statement implies the initiation of a relationship and care plan, indicating that the nurse is in the orientation phase rather than the termination phase.

C. “I see that you live near the hospital. Have you been living here a while?": This statement reflects rapport-building and exploration of the client’s background, which are part of the initial phases of the nurse-client relationship. It does not signify the termination phase.

D. “I’m going to miss talking with you every day but you are better and ready to go home now.": This statement clearly indicates the termination phase of the nurse-client relationship. It acknowledges the emotional aspect of the relationship while confirming that the client is prepared for discharge, signifying the conclusion of the care provided. This reflects a transition in the relationship as the nurse prepares to end interactions with the client.