The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

Correct Answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

Correct Answer: A

Rationale: The correct action is to assess the right radial pulse first because the client's symptoms (numbness in the right hand after a crushing injury to the right arm) suggest potential vascular compromise or compartment syndrome. A crushing injury can lead to swelling, increased pressure within the fascial compartments, and subsequent compression of nerves and blood vessels. The radial pulse is a direct indicator of arterial perfusion to the hand. If the pulse is weak or absent, this signals impaired blood flow, which is a medical emergency requiring immediate intervention to prevent tissue necrosis or permanent damage. Assessing the pulse provides critical data to guide further actions, such as notifying the provider or preparing for possible surgical intervention (e.g., fasciotomy). **Why other options are incorrect:** - **B: Call the provider** – While notifying the provider is important, it should occur *after* gathering initial assessment data (e.g., pulse, capillary refill, pain characteristics). Without assessing the radial pulse first, the nurse lacks objective information to communicate to the provider, which could delay appropriate treatment. The provider will need specific findings (e.g., pulse quality, signs of ischemia) to make clinical decisions. - **C: Administer pain medication** – Pain management is a priority in trauma, but numbness (not pain) is the primary symptom here, indicating possible neurovascular compromise. Administering analgesics without first assessing circulation could mask worsening symptoms (e.g., unrelenting pain from ischemia) and delay lifesaving interventions. Pain relief should follow the evaluation of vascular and neurological status. - **D: Assess the right pedal pulse** – A pedal pulse evaluates circulation to the foot, which is irrelevant in this scenario. The injury is localized to the arm, and the symptom (hand numbness) points to radial artery or peripheral nerve involvement in the upper extremity. Checking a pedal pulse wastes time and does not address the immediate concern. In summary, the radial pulse assessment is the most urgent action because it directly evaluates perfusion to the affected limb, aligns with the client's symptoms, and informs subsequent interventions. The incorrect choices either delay critical assessment, address unrelated systems, or prioritize less urgent interventions without proper clinical justification.

Correct Answer: D

Rationale: Conductive hearing loss occurs when sound waves cannot efficiently travel through the outer or middle ear to reach the inner ear. This type of hearing loss is often caused by mechanical blockages or malfunctions in the ear's conductive pathway. **Correct Answer: D (Otitis media)** Otitis media, an infection or inflammation of the middle ear, is a leading cause of conductive hearing loss. Fluid accumulation in the middle ear space due to infection or Eustachian tube dysfunction prevents the proper vibration of the ossicles (tiny bones in the ear), hindering sound transmission. This condition is particularly common in children and can be acute or chronic, often resolving with treatment but potentially leading to persistent hearing impairment if left untreated. **Incorrect Answer: A (Prolonged exposure to loud noises)** Prolonged exposure to loud noises typically causes **sensorineural hearing loss**, not conductive. This occurs due to damage to the hair cells in the cochlea (inner ear) or the auditory nerve, impairing the conversion of sound waves into neural signals. While noise-induced hearing loss is a significant concern, it does not involve mechanical obstruction or middle ear dysfunction, which are hallmarks of conductive hearing loss. **Incorrect Answer: B (Medications)** Certain medications, such as ototoxic drugs (e.g., aminoglycoside antibiotics, loop diuretics, chemotherapy agents), are known to cause **sensorineural hearing loss** by damaging the inner ear structures or auditory nerve. They do not affect the external or middle ear's ability to conduct sound, making this choice irrelevant to conductive hearing loss. **Incorrect Answer: C (Presbycusis)** Presbycusis is age-related hearing loss, which is **sensorineural** in nature. It results from the gradual degeneration of hair cells in the cochlea and other age-related changes in the auditory system. Unlike conductive hearing loss, presbycusis is not caused by physical blockages or middle ear issues but rather by the inner ear's diminished capacity to process sound. Conductive hearing loss is distinguished by its mechanical origins, such as earwax impaction, otitis media, or ossicular chain disruption, whereas sensorineural hearing loss involves nerve or cochlear damage. Understanding the anatomical and physiological differences between these types of hearing loss is crucial for accurate diagnosis and appropriate management.

Correct Answer: C

Rationale: **Rationale:** **C: Tinnitus** is a correct answer because it is a well-documented symptom of hearing loss. Tinnitus refers to the perception of ringing, buzzing, or other noises in the ears when no external sound is present. It often occurs due to damage to the hair cells in the cochlea, which are responsible for transmitting sound signals to the brain. This damage can result from prolonged exposure to loud noises, aging (presbycusis), or other underlying health conditions. Tinnitus is not a disease itself but a symptom of an auditory system malfunction, making it a strong indicator of hearing loss. Patients with tinnitus frequently report difficulty hearing external sounds clearly, further supporting its association with hearing impairment. **A: Answering questions correctly** is incorrect because this behavior does not indicate hearing loss. In fact, individuals with hearing loss may often answer questions incorrectly or inappropriately due to mishearing or not hearing the question at all. Those with mild to moderate hearing loss might rely on contextual clues or lip-reading to respond, but this is not a reliable sign of normal hearing. The ability to answer questions correctly is more indicative of cognitive function or comprehension rather than auditory health. Therefore, this option does not align with the signs of hearing loss. **B: Presence of cerumen** is incorrect because while excessive earwax (cerumen) can cause temporary conductive hearing loss by blocking the ear canal, it is not a definitive sign of hearing loss itself. Many people have cerumen buildup without experiencing hearing impairment, and the condition is easily treatable with proper ear cleaning. Hearing loss due to cerumen is usually reversible once the blockage is removed, unlike sensorineural hearing loss, which is permanent. Thus, the mere presence of cerumen is not a reliable or standalone indicator of hearing loss. **D: Frequent asking of others to repeat statements** is actually a correct sign of hearing loss, though it was not marked as such in the provided "correct answer." This behavior is a classic red flag for hearing impairment, as individuals struggling to hear clearly often ask others to repeat themselves. It suggests difficulty perceiving speech, especially in noisy environments or when speaking softly. This symptom is particularly common in age-related or noise-induced hearing loss, where high-frequency sounds (like consonants) become harder to distinguish. However, since the question’s designated correct answer was only C, this explanation highlights a discrepancy in the provided answer key. In summary, tinnitus (C) is a correct sign of hearing loss due to its direct link to auditory system damage, while answering questions correctly (A) is irrelevant, and cerumen (B) is only indirectly related. The exclusion of frequent requests for repetition (D) as a correct answer is inconsistent with clinical evidence, as it is a primary behavioral sign of hearing difficulty.

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.