A nurse is admitting a client to the surgical unit from the Post-Anesthesia Care Unit (PACU) following a cholecystectomy. Which of the following assessments is the nurse's priority?

Choice A reason:
A reddened area over the sacrum is a sign of potential pressure ulcer development, which is a common complication of immobility, especially in bedridden or wheelchair-bound individuals. The sacrum is a prominent bony area that bears weight when a person is sitting or lying down, making it susceptible to pressure ulcers if proper preventative measures, such as regular repositioning, are not taken.

Choice B reason:
Difficulty hearing some types of sounds is not typically a direct complication of immobility. Hearing issues may be related to other health conditions or age-related changes but are not caused by the lack of movement associated with post-stroke immobility.

Choice C reason:
Stiffness in the lower extremities can occur due to immobility, as muscles and joints may become tight when not used regularly. However, this is more of a long-term effect and may not be as immediately concerning as pressure ulcer prevention. Regular range-of-motion exercises can help prevent stiffness.

Choice D reason:
Difficulty moving the upper extremities may be a result of the stroke itself rather than a complication of immobility. While maintaining mobility in all limbs is important, the focus of monitoring should be on complications that arise specifically due to immobility, such as pressure ulcers.

Choice A reason:
The location of the burn is crucial in assessing the severity because burns to the face, neck, and upper extremities can compromise vital functions. For example, burns to the face may affect the airway and respiratory system, while burns to the hands can impair mobility and the ability to perform daily tasks. The depth of the burn at these locations also affects the severity assessment, as deeper burns can damage underlying tissues and structures.

Choice B reason:
While the age of the client can influence the healing process and the risk of complications, it is not the primary factor in assessing the initial severity of the burn. However, age is considered when planning treatment and rehabilitation, as children and the elderly may have different healing rates and responses to therapy.

Choice C reason:
The cause of the burn can provide context for potential complications, such as inhalation injury from a fire or chemical exposure. However, the immediate assessment of severity is more focused on the observable damage to the skin and underlying tissues rather than the cause of the burn.

Choice D reason:
The client's associated medical history is important for understanding potential risks and complications during the healing process, but it is not the primary factor in assessing the severity of the burn. The medical history will be more relevant when considering the client's overall prognosis and planning long-term care.