A nurse is performing a Weber test on a client who reports difficulty hearing in his left ear. The client informs the nurse that he can hear the tone louder in his left ear. Which of the following does this result indicate?

Choice A reason: This is the correct answer because airway obstruction is the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Airway obstruction can occur due to edema, inflammation, or inhalation injury of
the upper airway structures. It can compromise oxygenation and ventilation, and lead to respiratory failure or cardiac arrest. The nurse should assess for signs of airway obstruction, such as stridor, hoarseness, dyspnea, or cyanosis, and provide oxygen therapy, humidification, or intubation as needed.

Choice B reason: This is incorrect because fluid imbalance is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Fluid imbalance can occur due to fluid loss from damaged skin and capillaries, as well as increased capillary permeability and fluid shifts. It can cause dehydration, hypovolemia, shock, or electrolyte imbalances. The nurse should monitor fluid status, vital signs, urine output, and laboratory values, and provide fluid resuscitation as prescribed, but only after ensuring airway patency.

Choice C reason: This is incorrect because paralytic ileus is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Paralytic ileus is a condition where there is decreased or absent bowel motility due to nerve damage or decreased blood flow to
the gastrointestinal tract. It can cause abdominal distension, nausea, vomiting, or constipation. The nurse should assess bowel sounds, abdominal girth, and stool characteristics, and provide nasogastric suction or laxatives as prescribed, but only after ensuring airway patency and fluid balance.

Choice D reason: This is incorrect because infection is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Infection can occur due to loss of skin barrier, exposure to microorganisms, or impaired immune system. It can cause fever, increased pain, purulent drainage, or sepsis. The nurse should assess for signs of infection, obtain wound cultures, and administer antibiotics as prescribed, but only after ensuring airway patency, fluid balance, and pain control.

Choice A Reason: Colorectal cancer is not likely to cause nausea with projectile vomiting or high-pitched sounds in the left upper quadrant. Colorectal cancer may cause symptoms such as rectal bleeding, change in bowel habits, abdominal pain, or weight loss.

Choice B Reason: Paralytic ileus is a condition where the bowel stops working and does not contract or move food along. Paralytic ileus may cause symptoms such as abdominal distension, absence of bowel sounds, constipation, or vomiting.

Choice C Reason: Large bowel obstruction is a blockage of the colon or rectum that prevents the passage of stool. Large bowel obstruction may cause symptoms such as abdominal distension, low-pitched sounds in the right lower quadrant, constipation, or ribbon-like stools.

Choice D Reason: Small bowel obstruction is a blockage of the small intestine that prevents the passage of food and fluids. Small bowel obstruction may cause symptoms such as nausea with projectile vomiting, high-pitched sounds in the left upper quadrant, abdominal cramps, or dehydration.