A nurse is caring for an immobile client. What is the priority assessment of this client?

Correct Answer: C

Rationale: Inspecting the skin for injury is the priority assessment for an immobile client because prolonged immobility significantly increases the risk of pressure injuries (formerly called pressure ulcers or bedsores). These injuries develop due to unrelieved pressure on bony prominences (e.g., sacrum, heels, elbows), which compromises blood flow to the tissues, leading to ischemia, necrosis, and potential infection. Early identification of skin breakdown—such as non-blanchable erythema, blisters, or open wounds—allows for timely interventions like repositioning, pressure-relieving devices, and wound care, preventing further complications. Immobility also reduces sensory feedback, meaning the client may not feel discomfort, making visual inspection critical. Palpating for edema (A) is important but not the priority. Edema can indicate fluid retention or circulatory issues, but it is a secondary concern compared to the immediate risk of skin breakdown. While edema may exacerbate pressure injuries, it does not pose as acute a threat as undetected tissue damage. Similarly, auscultating for bowel sounds (B) assesses gastrointestinal motility, which can be impaired in immobile clients (e.g., due to slowed peristalsis or constipation). However, bowel dysfunction is less urgent than preventing or addressing skin integrity issues, which can rapidly deteriorate and lead to systemic infections like sepsis. Auscultation of lung sounds (D) is crucial for detecting complications like atelectasis or pneumonia, which immobile clients are at higher risk for due to shallow breathing and poor secretion clearance. However, these respiratory issues typically develop over time, whereas skin breakdown can occur within hours of unrelieved pressure. While respiratory assessment is vital, it does not supersede the need for immediate skin inspection, as pressure injuries can progress quickly and are often preventable with prompt action. The incorrect choices (A, B, D) represent important but lower-priority assessments for an immobile client. They address potential complications of immobility but fail to target the most immediate and preventable risk. Skin inspection (C) is the priority because it directly addresses the client’s highest vulnerability—pressure injuries—which require proactive monitoring to avert severe consequences. This prioritization aligns with the nursing principle of addressing the most critical, life-altering risks first.

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: A

Rationale: **Rationale:** **Correct Answer (A: Avoid home modification)** Avoiding home modifications is counterproductive to preventing musculoskeletal injuries in older adults. Home modifications—such as installing grab bars in bathrooms, improving lighting, removing tripping hazards, and adding stair railings—are proven strategies to reduce fall risks and subsequent fractures or sprains. Falls are a leading cause of musculoskeletal injuries in older adults, and modifications create a safer living environment. Ignoring these adaptations increases the likelihood of accidents, making this choice the least helpful advice. **Incorrect Answers:** **B: Wear a helmet when riding a bicycle** This is a valid preventive measure. While cycling, older adults are at risk of falls or collisions that could lead to fractures or traumatic injuries. A helmet protects against head injuries, which can indirectly prevent musculoskeletal harm by reducing the impact force transmitted to the neck, spine, and limbs. Though cycling may be less common in older adults, safety gear is still crucial for those who engage in such activities. **C: Osteoporosis screening** Osteoporosis screening is critical for older adults because it identifies bone density loss, a major risk factor for fractures. Early detection allows for interventions (e.g., calcium supplementation, weight-bearing exercises, or medications) that strengthen bones and reduce fracture risks. Since weakened bones exacerbate injury severity, screening directly contributes to musculoskeletal injury prevention. **D: Fall prevention** Fall prevention strategies (e.g., balance exercises, proper footwear, and medication reviews) are essential for older adults. Falls often result in fractures, dislocations, or soft tissue injuries, particularly in those with osteoporosis or muscle weakness. Proactive measures significantly lower injury risks, making this a highly effective teaching point. In summary, while options B, C, and D actively promote musculoskeletal safety, option A undermines injury prevention by discouraging necessary environmental adaptations.

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.