A nurse is teaching a 12yearold child who is newly diagnosed with asthma about managing the condition to prevent asthma attacks. Which of the following statements by the child should indicate to the nurse that the teaching has been effective?

Choice A reason: Difficulty moving the upper extremities is not a complication of immobility, but a result of the stroke. A stroke can damage the part of the brain that controls movement, sensation, or coordination of the limbs, causing hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body. The nurse should assist the client with passive or active range of motion exercises to prevent muscle atrophy and contractures.

Choice B reason: Stiffness in the lower extremities is not a complication of immobility, but a result of the stroke. A stroke can affect the muscle tone of the limbs, causing spasticity (increased muscle tension) or flaccidity (decreased muscle tone) on one side of the body. The nurse should apply splints or braces to prevent deformities and provide massage or stretching to relieve stiffness.

Choice C reason: A reddened area over the sacrum is a complication of immobility, and a sign of a pressure injury. A pressure injury is a localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear. The sacrum is a common site for pressure injuries, as it is a bony prominence that bears the weight of the body when lying down. The nurse should reposition the client every 12 hours, provide skin care, and use pressure relieving devices to prevent pressure injuries.

Choice D reason: Difficulty hearing some types of sounds is not a complication of immobility, but a result of aging or other factors. Hearing loss can occur due to various causes, such as exposure to loud noise, ear infections, earwax buildup, or ototoxic medications. The nurse should assess the client's hearing and use communication strategies, such as speaking clearly, facing the client, and reducing background noise.

Choice A reason: Repositioning the client toward the left side is not necessary or helpful for a client who has a three-chamber closed chest tube system. The chest tube drainage system must always be placed below the drainage site and secured in an upright position to prevent it from being knocked over.

Choice B reason: Continuing to monitor the client is the appropriate action for the nurse to take after noticing a rise in the water seal chamber with client inspiration. The water in the water seal chamber should rise with inhalation and fall with exhalation (this is called tidaling), which demonstrates that the chest tube is patent. This is a normal finding and does not indicate a problem with the chest tube system or the client's condition.

Choice C reason: Clamping the chest tube near the water seal is not recommended for a client who has a three-chamber closed chest tube system. Clamping the chest tube can cause a buildup of air or fluid in the pleural space and increase the risk of complications such as tension pneumothorax or infection. Clamping the chest tube should only be done in certain situations, such as changing the drainage system, checking for an air leak, or removing the chest tube.

Choice D reason: Immediately notifying the provider is not necessary for a client who has a three-chamber closed chest tube system and shows a rise in the water seal chamber with client inspiration. As mentioned above, this is a normal finding and does not indicate a problem with the chest tube system or the client's condition. The nurse should only notify the provider if there are signs of complications, such as continuous bubbling in the water seal chamber, excessive drainage, chest pain, dyspnea, or subcutaneous emphysema.