A client has a new arm cast. What is incorrect teaching by the nurse?

Correct Answer: D

Rationale: Rationale: **Correct Answer: D – Sudden increase in drainage is expected** A sudden increase in drainage from under a cast is **not normal** and indicates a potential complication, such as infection, bleeding, or tissue breakdown. This requires immediate medical evaluation to prevent further harm. Teaching the client to expect increased drainage is incorrect because it could lead to delayed reporting of serious issues, worsening the condition. **Incorrect Choices:** **A: Use a sling to alleviate fatigue** Using a sling is correct teaching because it supports the immobilized arm, reduces strain on muscles and joints, and prevents unnecessary movement that could displace the cast. A sling also helps maintain proper positioning, minimizing discomfort. This is appropriate nursing advice, not incorrect teaching. **B: Elevate the arm above the heart to reduce swelling** Elevation is a standard intervention to minimize swelling by promoting venous return and reducing fluid accumulation in the injured area. Failure to elevate can lead to increased pain, compromised circulation, or even compartment syndrome. This instruction is correct and should be reinforced, not dismissed. **C: Report 'hot spots' felt under the cast** A "hot spot" (localized warmth) under the cast is a red flag for infection or pressure necrosis. Early reporting allows prompt intervention, such as cast removal or antibiotic treatment. Teaching the client to monitor and report this is essential for preventing complications, making this correct guidance, not incorrect. **Summary of Errors in Choices A-C:** These options are all **correct nursing instructions** and would not represent incorrect teaching. Only **D** inaccurately normalizes a concerning symptom, posing a risk to the client’s recovery. Recognizing abnormal vs. expected post-cast symptoms is critical for patient safety.

Correct Answer: B

Rationale: Let’s analyze each option in detail to understand why **B** is the correct answer and why the others are incorrect. **Option B: The nurse cannot insert one finger between the cast and the skin** This is the correct answer because a properly applied cast should allow for slight swelling while maintaining immobilization. If the nurse cannot insert a finger between the cast and the skin, it indicates that the cast is **too tight**, which can lead to serious complications such as **compartment syndrome**. This condition occurs when increased pressure within a confined space (caused by swelling) restricts blood flow, potentially leading to tissue necrosis and permanent damage. Nurses must ensure there is enough space to accommodate expected post-cast swelling, and inability to insert a finger is a critical warning sign requiring immediate intervention, such as cast loosening or replacement. **Option A: The nurse assesses capillary refill of 2 seconds** A capillary refill time of **2 seconds is normal** and indicates adequate peripheral circulation. Delayed capillary refill (>3 seconds) would be concerning, as it suggests poor perfusion, possibly due to vascular compression or compromised circulation. Since 2 seconds falls within the expected range, this finding does not raise immediate concerns and is not the correct answer. **Option C: The nurse finds 2+ pulses distal from the cast** A **2+ pulse** is considered **normal** and indicates sufficient blood flow to the extremity. Diminished or absent pulses (0 or 1+) would be problematic, signaling possible vascular compromise, such as arterial occlusion or severe swelling obstructing circulation. Since 2+ pulses are expected in a healthy assessment, this finding does not warrant concern. **Option D: The nurse does not observe any drainage** The absence of drainage is typically **a normal and expected finding** in a fresh cast (unless there was an open wound pre-cast application). Drainage or foul odor would suggest complications like **infection or hemorrhage**, requiring further evaluation. Since no drainage is not a worrisome sign, this option is incorrect. In summary, **B** is the only choice indicating a potential **dangerous complication (cast tightness leading to impaired circulation or compartment syndrome)**, whereas the other findings are either normal or do not suggest immediate risk. Proper cast assessment prioritizes checking for tightness, circulation, sensation, and movement—any restriction in these areas must be addressed promptly to prevent permanent damage.

Correct Answer: D

Rationale: Immobility negatively impacts the cardiovascular system by disrupting normal hemodynamics, and the most significant consequence is **venous stasis (D)**. When a person is immobile for prolonged periods, skeletal muscle contractions—which normally assist venous return by compressing veins and propelling blood toward the heart—are minimized. This leads to blood pooling in the lower extremities, increasing venous pressure and causing stasis. Stasis raises the risk of **deep vein thrombosis (DVT)** due to sluggish blood flow, endothelial damage, and hypercoagulability. Additionally, immobility reduces the effectiveness of the venous valve system, further impairing circulation and exacerbating fluid accumulation in dependent tissues. **A ("Increased high-density lipoprotein")** is incorrect because immobility typically correlates with **reduced** HDL levels, not an increase. Physical inactivity is associated with unfavorable lipid profiles, including lower HDL (the "good" cholesterol) and higher LDL and triglycerides. HDL helps remove excess cholesterol, and its reduction worsens cardiovascular health. Immobility promotes metabolic dysregulation, contributing to atherosclerosis, contrary to the premise of this option. **B ("Increased circulation")** is incorrect because immobility **decreases** circulation. Normal circulation relies on movement—both physical activity and positional changes—to promote venous return via the muscle pump mechanism. Immobility stagnates blood flow, reducing cardiac output over time and impairing tissue perfusion. This can lead to complications like orthostatic hypotension (due to reduced vascular tone) and dependent edema, directly opposing the claim of improved circulation. **C ("Increased pumping action of the heart")** is incorrect because immobility **weakens** cardiac function. Prolonged inactivity reduces cardiac workload, leading to **cardiovascular deconditioning**. The heart’s pumping efficiency declines as stroke volume and cardiac output decrease due to reduced demand. Over time, this can cause myocardial atrophy (shrinking of heart muscle) and decreased aerobic capacity, the opposite of enhanced pumping action. The heart adapts to lower activity levels by becoming less efficient, not more. In summary, venous stasis (D) is the only plausible consequence of immobility, while the other choices describe outcomes that are either physiologically implausible (B, C) or opposite to the expected metabolic effects (A). The cardiovascular system relies on movement to maintain homeostasis, and immobilization disrupts this balance, posing significant risks like DVT, deconditioning, and impaired circulation.

Correct Answer: B

Rationale: **Rationale:** **Correct Answer (B): Reducing caffeine intake can decrease the risk of osteoporosis.** Caffeine has a mild diuretic effect, increasing calcium excretion through urine. Over time, excessive caffeine consumption (typically >3–4 cups of coffee per day) may contribute to decreased bone mineral density, particularly if calcium intake is insufficient. While caffeine alone is not a primary cause of osteoporosis, moderation helps preserve calcium balance, supporting bone health. **Incorrect Answer (A): Avoiding vitamin D would increase, not decrease, osteoporosis risk.** Vitamin D is essential for calcium absorption in the intestines. Without sufficient vitamin D, the body cannot effectively utilize dietary calcium, leading to weakened bones. Avoiding vitamin D would exacerbate bone loss, directly contradicting osteoporosis prevention strategies. **Incorrect Answer (C): Decreasing alcohol intake is correct, but the question asks for the nurse’s incorrect statement.** Excessive alcohol impairs osteoblast function (bone-forming cells) and interferes with calcium and vitamin D metabolism, increasing osteoporosis risk. However, this option is factually accurate, so its inclusion here suggests a misinterpretation of the question. If the question intended to identify only incorrect statements, this would not fit. **Incorrect Answer (D): Reducing protein intake would harm bone health.** Adequate protein is crucial for maintaining bone matrix integrity. Low protein intake is associated with reduced bone density and slower healing of fractures. While excessive protein without sufficient calcium may pose risks, protein restriction is not a recommended osteoporosis prevention strategy. **Key Takeaways:** - **Bone health requires balance:** Calcium, vitamin D, and protein are critical; caffeine and alcohol should be moderated. - **Misleading choices:** Avoiding vitamin D or protein directly undermines bone strength, while alcohol reduction (though correct) does not align with the question’s framing if seeking incorrect statements. - **Context matters:** The question likely tests recognition of harmful advice (A and D) versus beneficial actions (B and C), but assuming it requests incorrect statements, B stands alone as the accurate selection. **Clarifying Nuances:** - Caffeine’s effect is dose-dependent; moderate intake with adequate calcium may not pose significant risk. - Alcohol’s harm is dose-dependent, but abstinence is not required—moderation is key. - Vitamin D and protein are non-negotiable for bone health; their restriction is never advised. This rationale ensures students understand not just the correct answer but the physiological principles underlying each option, empowering them to apply this knowledge in clinical judgment.

Correct Answer: B

Rationale: The client's report of bilateral, painless blurred vision strongly suggests cataracts as the most likely condition. Cataracts develop when the lens of the eye becomes cloudy, leading to progressive, painless vision impairment that typically affects both eyes (though often asymmetrically). This clouding scatters light entering the eye, causing blurred vision that may be described as looking through a foggy window. Cataracts are particularly associated with aging (age-related cataracts), but can also result from trauma, medications like steroids, or systemic conditions like diabetes. The bilateral presentation without pain aligns perfectly with cataract symptoms, as they rarely cause discomfort unless they reach an advanced stage. Macular degeneration (A) primarily affects central vision rather than causing generalized blurring, and typically presents with specific distortions like straight lines appearing wavy (metamorphopsia) or central scotomas (blind spots). While it can be bilateral, macular degeneration wouldn't typically cause symmetrical blurring without these distinctive features. Retinal detachment (C) usually presents with unilateral symptoms like sudden flashes of light (photopsia), floaters, or a "curtain" over the visual field rather than gradual bilateral blurring. While painless, retinal detachment is typically an acute event with distinct symptoms that differ from the described presentation. Glaucoma (D) in its most common form (open-angle) is indeed painless, but visual changes typically begin with peripheral vision loss, not generalized blurring. Angle-closure glaucoma can cause sudden blurring but is accompanied by severe pain, nausea, and halos around lights, making it inconsistent with this presentation. The key distinguishing factors here are the bilateral nature of symptoms, absence of pain, and the characteristic blurred (rather than lost) vision. Cataracts progress slowly, explaining why the blurring develops gradually without other symptoms. The lens opacity in cataracts affects all light entering the eye uniformly, unlike macular degeneration which targets central vision or glaucoma that attacks peripheral vision first. None of the other options present with this exact combination of features, making cataract the only plausible explanation among the choices given. Additional supporting evidence would include age (most common in those over 60), possible complaints of glare sensitivity, or difficulty with night vision—all hallmark symptoms of cataracts that further confirm this as the correct answer.