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 B

Explanation

A. The client leans to the left side while sitting: While leaning to one side may indicate weakness or impaired balance, it is not as immediately concerning as the risk of aspiration. Addressing issues related to positioning and balance is important but may not pose an immediate threat to the client's safety.

B. The client coughs frequently while eating.

Coughing frequently while eating can indicate a risk of aspiration, which is a serious concern in stroke patients with left-sided weakness. Aspiration can lead to pneumonia and other respiratory complications. Therefore, it is crucial for the nurse to address this finding promptly to prevent potential respiratory compromise.

C. The client is consuming 25% of their meals: Poor oral intake and difficulty eating are concerning but do not pose an immediate threat to the client's safety compared to the risk of aspiration. However, addressing inadequate nutrition and hydration is essential for the client's overall health and recovery.

D. The client's blood pressure is 142/94 mm Hg: While monitoring blood pressure is important, especially in stroke patients who may have hypertension, the blood pressure reading provided does not indicate a hypertensive crisis or immediate risk to the client's safety. Therefore, it is not the priority finding compared to the risk of aspiration.

A. Supine in low-Fowler's position B. Side-lying with the right side of the chest elevated C. Prone with pillows under the lower extremities D. Right lateral in Trendelenburg position

Correct Answer is D

Explanation

A. Supine in low-Fowler's position:Low-Fowler's position does not effectively promote postural drainage for left lower-lobe atelectasis. This position would not use gravity to facilitate mucus drainage or improve ventilation to the affected lobe.

B. Side-lying with the right side of the chest elevated:While side-lying positions can be useful for postural drainage, lying with the right side elevated does not optimize drainage from the left lower lobe.

C. Prone with pillows under the lower extremities:Although the prone position can help improve oxygenation in some respiratory conditions, it is not ideal for targeting left lower-lobe atelectasis in postural drainage therapy.

D. Right lateral in Trendelenburg position:In this position, the left lower lobe is elevated, allowing gravity to assist in draining secretions toward the larger airways for clearance. The Trendelenburg position further enhances the effect of gravity on secretion drainage from the lower lobe.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?

Correct Answer is D

Explanation

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