A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?

Correct Answer: A

Rationale: The best initial action is to inquire about the frequency, quality, and location of the pain (Option A). Pain assessment is the first critical step in nursing care because it provides essential information needed to determine the appropriate intervention. Without a thorough understanding of the pain’s characteristics—whether it is sharp, dull, throbbing, localized, or radiating—the nurse cannot effectively advocate for the patient or make informed clinical decisions. Proper pain assessment also helps differentiate between expected cancer-related pain and potential complications, such as a new fracture or infection, which may require immediate medical attention. This step ensures that subsequent interventions, including medication administration, are tailored to the patient’s specific needs rather than being applied generically. Option B (Get the client pain medication) may seem urgent, but administering medication without a proper assessment risks inappropriate dosing, masking critical symptoms, or overlooking complications. Pain management is important, but it must be based on a clear understanding of the pain’s nature and severity. Blindly administering medication could delay identifying a more serious issue, such as pathological fracture or spinal cord compression, which requires additional interventions beyond analgesia. Option C (Ensure the client knows he will have negative effects from immobility) is inappropriate as an initial response. While immobility complications (e.g., muscle atrophy, pressure injuries, or thrombus formation) are legitimate concerns, they are secondary to addressing the patient’s acute pain. Educating the patient about immobility risks at this moment dismisses their immediate distress and fails to prioritize their most pressing need—pain relief. This approach could also erode trust, as the patient may perceive the nurse as minimizing their suffering. Option D (Review the client’s medication administration record) is a useful step but should follow, not precede, a pain assessment. Reviewing the MAR provides information on previously administered medications, scheduled doses, and potential gaps in pain management. However, without first assessing the current pain, the nurse lacks context for interpreting the MAR’s data. For example, if the pain is new or worsening despite recent medication, this could signal a need for reevaluation of the treatment plan rather than simply administering the next scheduled dose. In summary, pain assessment (Option A) is foundational. It ensures patient-centered care, guides safe and effective interventions, and prevents oversight of critical clinical changes. The other options, while relevant, should only be pursued after a thorough assessment or as part of a broader pain management strategy.

Correct Answer: B

Rationale: **Rationale:** **Correct Answer (B: Contractures):** Contractures are a direct and significant negative effect of immobility on the musculoskeletal system. Prolonged immobility leads to shortening and stiffening of muscles, tendons, and ligaments due to disuse and lack of stretching. This occurs because muscles and connective tissues adapt to the shortened position they are held in, losing elasticity and range of motion. For example, if a joint remains bent for an extended period (e.g., a knee or elbow), the surrounding tissues may permanently tighten, making it difficult or impossible to straighten the joint. Contractures can cause pain, limit mobility further, and require physical therapy or surgical intervention to correct. This musculoskeletal complication is distinct from other systems and directly tied to the lack of movement. **Incorrect Answers:** **A: Pressure injury** While pressure injuries (e.g., bedsores) are a serious complication of immobility, they primarily affect the integumentary system (skin and underlying tissues), not the musculoskeletal system. These injuries result from prolonged pressure on skin over bony prominences (e.g., heels, sacrum), reducing blood flow and causing tissue necrosis. Though immobility contributes to pressure injuries, they are not a musculoskeletal-specific effect like contractures. **C: Glucose intolerance** Glucose intolerance is a metabolic consequence of immobility, not a musculoskeletal one. Reduced physical activity decreases muscle mass and insulin sensitivity, impairing the body's ability to regulate blood sugar. However, this is a systemic metabolic issue involving hormonal and cellular processes, not a structural or functional change in muscles, bones, or joints. **D: Incontinence** Incontinence is a urinary or bowel dysfunction often associated with immobility but is unrelated to the musculoskeletal system. It arises from weakened pelvic floor muscles, nerve damage, or reduced mobility preventing timely bathroom access. While immobility can contribute to incontinence, the root cause lies in the urinary or digestive systems, not the muscles, bones, or joints. **Key Distinction:** The question specifically asks about the musculoskeletal system, and **contractures** are the only option directly involving muscles, tendons, and joints. The other choices are secondary effects of immobility but pertain to other body systems. Understanding this system-specific impact is critical for targeted interventions, such as range-of-motion exercises to prevent contractures, while pressure injuries require skin care, glucose intolerance demands metabolic management, and incontinence necessitates bladder or bowel retraining.

Correct Answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.

Correct Answer: A

Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.

Correct Answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.