A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients.
Which of the following statements should the nurse make?

Choice A rationale:

Allowing extra time to communicate with the client is a crucial action when caring for a client with impaired speech. This approach respects the client's autonomy and ensures that they have the time they need to express themselves. It is an appropriate and compassionate response to the client's condition.

Choice B rationale:

Finishing sentences for the client is not recommended because it interferes with the client's ability to communicate independently. It does not respect the client's autonomy and may lead to frustration.

Choice C rationale:

Avoiding the use of visual aids for communication is not a best practice, especially for clients with impaired speech. Visual aids can enhance communication and should be used when appropriate.

Choice D rationale:

Asking open-ended questions is a good communication strategy, but it is not the first action to take. Allowing extra time for communication should be the initial step when caring for a client with impaired speech.

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.