A nurse is preparing to obtain a 24-hr urine collection from a client.
Which of the following actions should the nurse plan to take?

Choice A rationale:

The statement, "Depression," does not align with the client's promise to go to church every day if they get better. Depression is one of the Kubler-Ross stages of grief, but it does not reflect the client's behavior of making promises to engage in specific activities if they improve. Therefore, this choice does not represent the client's current stage of grief accurately.

Choice B rationale:

The client's statement, "If I get better, I promise to go to church every day," indicates that the client is in the bargaining stage of grief. During this stage, individuals often make deals or promises in an attempt to reverse or delay the terminal diagnosis or adverse outcome. This response reflects the typical behavior associated with the bargaining stage, making it the correct choice.

Choice C rationale:

The statement, "Denial," is not consistent with the client's promise to go to church every day. Denial is a stage in which individuals may refuse to accept the reality of their situation and may not engage in making promises or deals. Therefore, this choice does not accurately represent the client's current stage of grief.

Choice D rationale:

The statement, "Anger," does not align with the client's promise to go to church every day. Anger is another stage of grief, characterized by frustration and resentment, but it does not correspond to the client's behavior of making promises. This choice does not accurately reflect the client's current stage of grief.

Choice A rationale:

The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.

Choice B rationale:

The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.

Choice C rationale:

The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.

Choice D rationale:

The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.