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

Correct Answer: C

Rationale: Immobility significantly increases the risk of pressure injuries (pressure ulcers) due to prolonged pressure on bony prominences, reduced blood flow, and potential shear forces from sliding or improper repositioning. The skin integrity of an immobile client must be inspected frequently—ideally every 2 hours—because early signs of injury (e.g., erythema, blisters, or tissue breakdown) require immediate intervention to prevent progression to severe wounds. Pressure injuries can develop rapidly (within hours) and lead to infections, prolonged hospitalization, or systemic complications. This makes skin inspection the **priority** assessment, as it addresses the most immediate and preventable threat to the client’s well-being. **Why other options are incorrect:** - **A: Palpate for edema** While edema assessment is important (e.g., for detecting DVT or fluid retention), it is not the **priority** for an immobile client. Edema may develop over time and is less immediately life-threatening than skin breakdown. Additionally, edema alone does not guide urgent interventions unless paired with other symptoms (e.g., pain or asymmetry suggesting thrombosis). - **B: Auscultate for bowel sounds** Immobility can slow gastrointestinal motility (leading to constipation or ileus), but bowel sounds are not the **first** priority. Bowel dysfunction typically develops over days and is not as immediately harmful as skin compromise. Monitoring bowel function is important but secondary to preventing pressure injuries. - **D: Auscultation of lung sounds** While immobility increases the risk of atelectasis or pneumonia due to shallow breathing, lung sounds are not the **priority** in the initial assessment. Respiratory complications usually manifest later (e.g., after 48–72 hours of immobility). Skin inspection takes precedence because it can prevent irreversible damage with early detection. In summary, **C** is correct because skin inspection directly addresses the most urgent and preventable complication of immobility (pressure injuries), while the other assessments are important but secondary in the immediate context. The rationale aligns with nursing priorities: preventing harm that is both rapid in onset and high in severity.

Correct Answer: D

Rationale: The correct answer is D because sudden increases in drainage from a cast are **never** expected and indicate a potential complication, such as infection or bleeding. A new cast may have minimal moisture initially from the casting material, but any sudden or significant increase in discharge is abnormal and requires immediate medical evaluation. This would suggest wound deterioration or infection beneath the cast, which could compromise healing and require intervention. **Why the other options are incorrect:** - **A (Use a sling to alleviate fatigue):** This is correct teaching. A sling helps support the arm, reducing muscle strain and discomfort, especially in the early stages of healing. It prevents excessive movement that could disrupt the cast or underlying injury. While it does not replace elevation for swelling, it is a valid recommendation for comfort and stability. - **B (Elevate the arm above the heart to reduce swelling):** This is appropriate post-cast care. Elevation minimizes edema by promoting venous return and reducing fluid accumulation in the injured area. Persistent swelling can cause pressure under the cast, leading to impaired circulation or compartment syndrome, so this instruction is essential. - **C (Report 'hot spots' felt under the cast):** This is critical teaching. A localized burning or "hot spot" may indicate pressure ulcers, infection, or tissue necrosis developing beneath the cast. Early reporting allows for timely assessment and cast adjustment to prevent further tissue damage. Ignoring this symptom could lead to serious complications. In contrast, **D** is dangerously incorrect because drainage should decrease over time, not increase. New drainage—especially if purulent, bloody, or foul-smelling—signals an active problem. The nurse must educate the client to recognize abnormal signs and seek care rather than dismissing them as expected. Proper monitoring prevents avoidable complications like osteomyelitis or delayed healing. Understanding these distinctions ensures safe post-cast management.

Correct Answer: A

Rationale: **Rationale:** **Choice A (Avoid home modification)** is the correct answer because it actively opposes measures that protect older adults from musculoskeletal injuries. Home modifications—such as installing grab bars, improving lighting, removing tripping hazards, and using non-slip mats—are essential for reducing fall risks and creating a safer living environment. Avoiding these modifications increases the likelihood of falls, fractures, and other musculoskeletal injuries, making this choice counterproductive to injury prevention. **Choice B (Wear a helmet when riding a bicycle)** is incorrect because helmet use is crucial for preventing head injuries, which can indirectly protect against musculoskeletal trauma. While the primary benefit of helmets is reducing traumatic brain injuries, they also minimize the risk of cervical spine and facial fractures. Encouraging protective gear aligns with injury prevention strategies, even if the direct focus is not solely on the musculoskeletal system. **Choice C (Osteoporosis screening)** is incorrect because osteoporosis screening is a proactive measure to identify bone density loss early, allowing for interventions like calcium supplementation, weight-bearing exercises, and medications to strengthen bones. Weak bones are more susceptible to fractures, even from minor falls. Early detection and management reduce fracture risk, directly supporting musculoskeletal health. **Choice D (Fall prevention)** is incorrect because fall prevention strategies—such as balance exercises, proper footwear, and assistive devices—are foundational to avoiding musculoskeletal injuries in older adults. Falls are a leading cause of fractures, sprains, and soft tissue damage in this population. Teaching fall prevention methods is evidence-based and directly supports musculoskeletal safety. **Conclusion:** The key distinction lies in recognizing that **Choice A** is the only option that actively undermines injury prevention, while the others promote protective measures. Home modifications are a well-documented, effective intervention, and discouraging them would leave older adults vulnerable to avoidable harm. The incorrect choices either directly or indirectly contribute to musculoskeletal safety, reinforcing their validity as helpful health teachings.

Correct Answer: B

Rationale: **Rationale:** **Correct Answer (B): The nurse cannot insert one finger between the cast and the skin** A properly applied cast should allow the nurse to insert one finger between the cast and the client’s skin to ensure there is adequate space to accommodate potential swelling. If the cast is too tight and prevents this, it indicates excessive pressure on the underlying tissues, increasing the risk of complications such as **compartment syndrome**—a medical emergency where increased pressure within a muscle compartment restricts blood flow, potentially causing tissue necrosis and permanent damage. This finding requires immediate intervention, such as cast loosening or bivalving, to prevent limb ischemia and nerve damage. **Incorrect Answers:** **A: The nurse assesses capillary refill of 2 seconds** A capillary refill time of **2 seconds is normal** and indicates adequate peripheral perfusion. Delayed capillary refill (>3 seconds) would be concerning, as it suggests poor circulation, possibly due to vascular compromise from swelling or cast tightness. Since this value is within the expected range (1–3 seconds), it does not indicate a problem. **C: The nurse finds 2+ pulses distal from the cast** The presence of **2+ pulses distal to the cast** (on a scale of 0–4+) confirms that arterial blood flow is intact. Absent or diminished pulses would raise concern for vascular compromise, but **2+ pulses are a reassuring finding** and suggest no immediate circulatory impairment. **D: The nurse does not observe any drainage** The absence of drainage is **expected** in a fresh cast (4 hours post-application). Drainage would only be concerning if the cast were older or if there were signs of bleeding, infection (e.g., foul odor, purulent discharge), or an open wound beneath the cast. Since no drainage is present, this finding is not indicative of a problem. **Key Takeaway:** The inability to insert a finger under the cast is the most critical finding because it suggests excessive constriction, which can lead to severe complications like compartment syndrome. Other findings (normal capillary refill, intact pulses, no drainage) are either expected or non-alarming in this scenario. Immediate action is required for a cast that is too tight to prevent irreversible tissue damage.

Correct Answer: a

Rationale: Deep vein thrombosis (DVT) is a significant postoperative complication, particularly following orthopedic surgeries like hip reduction and fixation, due to venous stasis, endothelial injury, and hypercoagulability (Virchow’s triad). Analyzing each option reveals why certain clients are at higher risk: **A: A client on birth control pills** - Correct. Estrogen-containing oral contraceptives increase clotting factors (e.g., fibrinogen, factors VII, VIII) and decrease anticoagulant proteins (e.g., protein S), creating a hypercoagulable state. Postoperative immobility exacerbates this risk. Studies show a 3- to 5-fold higher DVT risk in users, especially when combined with surgery. **B: A client who is immobile** - Correct. Immobility is a major DVT risk factor. Reduced muscle contraction in the lower extremities slows venous return, causing stasis. Post-hip surgery, clients often have limited mobility due to pain or restrictions, further increasing stasis-related clot formation. Early mobilization is critical to mitigate this. **C: A client on an anticoagulant** - Incorrect. Anticoagulants (e.g., heparin, warfarin) reduce clotting risk by inhibiting thrombin or vitamin K-dependent factors. While no medication eliminates DVT risk entirely, these clients are *less* likely to develop clots compared to untreated individuals. This option describes a protective, not risk, factor. **D: A client with dementia who has been wandering** - Incorrect. Wandering implies ambulation, which promotes venous return and reduces stasis. While dementia may pose other challenges, mobility lowers DVT risk. If the client were sedentary or restrained, the answer might differ, but wandering itself is protective. **Key Takeaways**: Hormonal therapy (A) and immobility (B) directly align with Virchow’s triad. Anticoagulants (C) reduce risk, and wandering (D) counters stasis. Understanding these mechanisms helps identify high-risk clients for prophylactic interventions like compression devices or early ambulation.