What are signs of hearing loss? (Select all that apply)

Correct Answer: C

Rationale: **Rationale:** **Choice C (Tinnitus) is correct** because tinnitus—a ringing, buzzing, or hissing sound in the ears—is a common symptom of hearing loss. It often results from damage to the hair cells in the cochlea or other auditory pathways, which can occur due to noise exposure, aging (presbycusis), or medical conditions. Tinnitus is frequently associated with sensorineural hearing loss, as the brain may compensate for reduced auditory input by generating phantom sounds. While tinnitus can occur independently, its presence alongside other symptoms strongly suggests hearing impairment. **Choice A (Presence of cerumen) is incorrect** because earwax (cerumen) is a normal bodily secretion that protects the ear canal. While excessive cerumen can cause temporary conductive hearing loss by blocking sound waves, its mere presence is not a definitive sign of hearing loss. Many individuals have cerumen without any auditory issues, and the problem is easily resolved with proper ear hygiene or medical removal. **Choice B (Presence of cerumen) is repeated and thus redundant**. It is the same as Choice A, and the rationale for its incorrectness remains identical. Redundant options in a question are typically errors and should not be considered valid distinct choices. **Choice D (Frequent asking of others to repeat statements) is incorrect** in this context because while it is a behavioral sign of hearing difficulty, the question specifies "signs of hearing loss," which typically refer to physiological or sensory indicators (e.g., tinnitus). Behavioral cues like asking for repetitions are secondary manifestations rather than direct signs. However, in clinical practice, this would still be relevant for diagnosing hearing impairment—just not the best fit for this question’s phrasing. The focus on **tinnitus (C)** as the correct answer highlights a primary sensory symptom directly linked to hearing loss mechanisms, whereas the other options either describe normal physiology (cerumen) or indirect behavioral effects (asking for repetitions). The repetition of Choice B further invalidates it as a distinct option. Understanding the distinction between direct symptoms and secondary effects is critical for accurately identifying hearing loss.

Correct Answer: D

Rationale: Administering eye drops correctly is critical to ensuring medication efficacy and preventing contamination or injury. The correct technique involves strict hygiene and avoiding direct contact between the dropper and the eye. **Why D is correct (the action needing further education):** Touching the dropper to the eye introduces a high risk of contamination. The dropper tip can pick up bacteria or debris from the eye, eyelashes, or surrounding skin, which may then contaminate the entire bottle of medication. Additionally, physical contact can cause microabrasions to the cornea or lead to accidental injury if the patient moves suddenly. Proper technique requires holding the dropper slightly above the eye (about 1-2 cm) to allow the drop to fall into the conjunctival sac without contact. **Why A is incorrect (acceptable action):** Setting the cap down in a non-contaminated manner (e.g., placing it on a clean tissue or holding it with the inner side facing upward) prevents exposure to dirt or microbes. Since the cap must be removed to administer drops, ensuring it remains clean is part of proper sterile technique. This action does not require correction. **Why B is incorrect (proper technique):** Instilling drops directly into the conjunctival sac (the pocket between the lower eyelid and eyeball) ensures optimal absorption and minimizes spillage. This area is less sensitive than the cornea, reducing discomfort. Dropping medication onto the cornea directly can cause irritation or reflexive blinking, leading to wasted medication. The client’s action here is correct. **Why C is incorrect (essential step):** Handwashing before handling eye drops is a fundamental infection control measure. Pathogens from unwashed hands can transfer to the eye or dropper, increasing the risk of infection (e.g., conjunctivitis). This step is non-negotiable in eye care and does not indicate a need for further teaching. **Key Takeaways for Proper Eye Drop Administration:** - Avoid dropper-to-eye contact to prevent contamination and injury. - Target the conjunctival sac for comfortable and effective delivery. - Maintain sterility by washing hands and handling the cap carefully. - Never touch the tip of the dropper to any surface, including the eye. Missteps like touching the dropper to the eye (D) compromise both safety and sterility, making it the clear indicator for additional client education. The other options (A, B, C) reflect correct practices that align with standard protocols for ophthalmic medication administration.

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.