What is the best nursing intervention for a client with limited mobility who cannot move independently?

Correct Answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

Correct Answer: A

Rationale: **Rationale:** **A: Client who had recent cataract surgery and worsening vision** is the highest priority. Postoperative complications following cataract surgery, such as endophthalmitis (a severe intraocular infection) or retinal detachment, can lead to rapid and irreversible vision loss if not addressed immediately. Worsening vision after cataract surgery is a red flag that demands urgent evaluation to rule out these sight-threatening conditions. Delay in treatment could result in permanent damage, making this client the top priority. **B: Client with an absent red reflex** is concerning but may not always require immediate intervention. An absent red reflex can indicate conditions like retinal detachment, vitreous hemorrhage, or advanced cataracts. While serious, some causes (e.g., dense cataract) may not be emergencies, whereas others (e.g., retinal detachment) would be. However, without additional symptoms like acute vision loss or pain, this finding alone is less urgent than a postoperative complication. **C: Client with an intraocular pressure (IOP) of 24 mmHg** is not the most urgent case. While elevated IOP can suggest glaucoma, 24 mmHg is only mildly elevated and may not cause immediate harm. Acute angle-closure glaucoma (which presents with severe pain, vision loss, and IOP >40 mmHg) would be emergent, but this scenario lacks those symptoms. This client can be seen after more urgent cases. **D: Client with a tearing, reddened eye with exudate** likely has conjunctivitis, which, while uncomfortable, is typically non-vision-threatening and not an emergency. Bacterial or viral conjunctivitis can be managed with topical treatments and does not require immediate attention unless there is corneal involvement or severe pain, which is not indicated here. This client can wait compared to the postoperative case. In summary, **A** is the correct answer because postoperative vision changes after cataract surgery are potentially sight-threatening and require immediate assessment. The other options involve conditions that, while notable, are either less urgent or lack the immediate risk of permanent vision loss.

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.