A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?

"The food is not great, but it is nice not having to do all of my own cooking."

"I don't want to go to the activity room because none of the other residents can hear."

"The staff sometimes have to remind me to use a cane when I walk in the hall."

"When I go out, I've been using public transportation since I can't drive anymore

Answer and Explanation

The Correct Answer is B

Correct answer: B

A. "The food is not great, but it is nice not having to do all of my own cooking.":

This statement acknowledges a minor issue with the food but overall expresses satisfaction with the convenience of not having to cook, indicating some level of acceptance of the transition.

B. "I don't want to go to the activity room because none of the other residents can hear."

This statement suggests a feeling of disconnection or dissatisfaction with the activities available in the assisted living facility. The client may be expressing frustration or a sense of isolation because the other residents cannot hear, which could hinder their ability to engage socially and participate in activities. Difficulty accepting the transition may manifest as resistance or reluctance to participate in aspects of facility life, such as group activities, due to perceived limitations or barriers.

C. "The staff sometimes have to remind me to use a cane when I walk in the hall.":

While this statement may indicate some adjustment to the need for assistance or reminders, it does not necessarily suggest difficulty accepting the transition. Instead, it reflects a willingness to comply with safety recommendations provided by the staff.

D. "When I go out, I've been using public transportation since I can't drive anymore":

This statement acknowledges a change in transportation habits due to inability to drive, which may be a practical adaptation to the client's circumstances rather than a sign of difficulty accepting the transition to assisted living.

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Correct Answer is C

Explanation

A. Reposition the client every 4 hours:

While repositioning is essential for preventing pressure injuries, the recommended frequency for repositioning depends on the individual client's condition, risk factors, and facility protocols. Four-hour intervals may not be sufficient for some clients, especially those at higher risk, and more frequent repositioning may be necessary.

B. Raise the head of the client's bed to a 60° angle:

Raising the head of the bed to a 60° angle may help with positioning for comfort and respiratory support but does not directly address the prevention of pressure injuries. In fact, maintaining the head of the bed elevated at such a high angle for prolonged periods could potentially increase pressure on the sacrum and increase the risk of pressure injuries in other areas.

C. Ensure the client's heels are not touching the mattress.

Keeping the client's heels off the mattress helps to alleviate pressure on this vulnerable area, reducing the risk of pressure injuries. Pressure injuries commonly occur over bony prominences when pressure is exerted on the skin over an extended period, leading to tissue damage. The heels are particularly susceptible due to the limited tissue padding and continuous pressure when lying in bed. Elevating the heels with appropriate support, such as foam pads or pillows, helps to redistribute pressure and minimize the risk of pressure injuries.

D. Massage the client's bony prominences:

Massaging bony prominences is contraindicated for clients at risk of pressure injuries as it can increase friction and shear forces on the skin, leading to tissue damage. Massage should be avoided over areas prone to pressure injuries to prevent further trauma to the skin.

A. Use trochanter rolls beside the client's legs. B. Place the client's arms at their side when turning them. C. Cross the client's ankles when lying supine. D. Logroll the client every 4 hr.

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.

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A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?

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