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

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: D

Rationale: Administering eye drops correctly is critical for both medication efficacy and infection prevention. The action described in **Choice D (touching the dropper to the eye)** clearly indicates a need for further education because it introduces contamination risks. The dropper tip should never contact the eye, eyelids, or any other surface, as this can introduce bacteria or other pathogens into the medication bottle, leading to potential infections like conjunctivitis or keratitis. Proper technique involves holding the dropper close to the eye (about an inch away) without making direct contact to maintain sterility. **Choice A (setting the cap down without contaminating it)** is correct and does not require additional teaching. Placing the cap in a clean, dry location (e.g., upside down on a tissue) prevents contamination, ensuring the medication remains sterile. This demonstrates the client’s understanding of aseptic technique. **Choice B (dropping medication into the conjunctival sac)** is also correct. The conjunctival sac, the pocket formed by pulling down the lower eyelid, is the ideal location for instilling drops. This ensures proper absorption and minimizes spillage. The client’s ability to target this area correctly shows they have been taught the proper administration technique. **Choice C (washing hands before instilling drops)** reflects proper hygiene and is essential to prevent transferring pathogens from the hands to the eye. Handwashing reduces the risk of infection, and the client’s adherence to this step indicates they are following best practices. In summary, **Choice D** is the only option that reveals a critical error in technique, as it compromises sterility and increases infection risk. The other choices (A, B, and C) demonstrate correct practices that align with standard eye drop administration protocols. Clients must be reminded to avoid touching the dropper to the eye or any surface to maintain medication safety and effectiveness. Correcting this behavior is crucial to ensure therapeutic outcomes and prevent complications.

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.