A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following client statements indicates an understanding of the nurse's instructions?

a.Frequent bathing can actually worsen dry, itchy skin as it can strip away the natural oils that help moisturize the skin. Instead, the nurse should encourage the client to limit bathing to shorter durations using lukewarm water and gentle, fragrance-free cleansers.

b.Powder may not provide significant relief for dry, itchy skin and can potentially irritate the skin further. It is best to focus on moisturizing and hydrating the skin to alleviate the symptoms.

c.While this might seem helpful, oils in the bath can create a slippery surface, posing a fall risk, especially for older adults. Additionally, oils might not provide sufficient hydration to the skin and could leave a residue that is not always beneficial.

d.Dry, itchy skin is a common concern among older adults, and it can be exacerbated by low humidity levels. Placing a humidifier in the client's room helps to increase the moisture content in the air, which can alleviate dryness and itchiness. The increased humidity can help prevent the skin from becoming overly dry and can provide relief from the symptoms.

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries.This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.