A nurse in an urgent care center is caring for a young adult client who requires suturing of a laceration. The client tells the nurse, "My family should have been here by now. I can't go through this without them." Which of the following responses should the nurse make?

Rationale

A. "My hearing has improved since I got my hearing aids.": This statement reflects a positive adaptation to age-related sensory changes and does not indicate a disturbed body image. The client demonstrates acceptance and use of assistive devices to maintain function.

B. "I avoid going out because I sometimes have problems with incontinence.": Avoiding social situations due to incontinence suggests the client is experiencing distress or embarrassment about physical changes, reflecting an impaired body image. This avoidance can affect self-esteem, social engagement, and overall quality of life.

C. "These lines in my face reveal a part of my character.": This statement shows the client has a positive perception of aging and views physical changes as meaningful rather than negative, indicating a healthy body image.

D. "My wrinkled hands show how hard I've worked all my life.": The client interprets physical aging positively, associating wrinkles with experience and effort, which demonstrates acceptance of bodily changes and a preserved body image.

Rationale

A. Apply an abduction pillow to the legs: An abduction pillow is used to maintain proper hip alignment, especially after hip surgery, but it does not prevent plantar flexion contractures. Its purpose is to keep the lower extremities in proper abduction rather than address ankle mobility.

B. Use a trochanter roll: A trochanter roll helps prevent external rotation of the hip in immobile clients but does not influence ankle positioning. While important for hip alignment, it does not prevent plantar flexion contractures of the feet.

C. Use foot splints: Foot splints (or ankle-foot orthoses) maintain the feet in a neutral position, preventing plantar flexion and subsequent contracture. Regular use supports joint flexibility, reduces muscle shortening, and helps preserve functional mobility in immobile clients.

D. Prop the feet up: Elevating the feet may relieve pressure and promote circulation, but it can allow the toes to point downward and contribute to plantar flexion over time. This method is not effective in preventing contractures and may worsen the problem if used as the sole intervention.