A nurse is caring for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Monitor the client for an elevated temperature.
Ensure the halo jacket is snug against the client's skin.
Provide range of motion to the client's neck
Remove the vest daily to inspect the client's skin integrity.
The Correct Answer is A
Choice A Reason:
Monitoring the client for an elevated temperature is crucial because it can indicate an infection at the pin sites or other complications. Infections are a common risk with halo fixation devices due to the invasive nature of the pins.
Choice B Reason:
Ensuring the halo jacket is snug against the client's skin is incorrect. The halo jacket should fit properly but not be too tight, as this can cause skin breakdown and discomfort. There should be enough space to insert a flat hand between the vest and the skin.
Choice C Reason:
Providing range of motion to the client's neck is not appropriate for a client with a halo fixation device. The purpose of the halo is to immobilize the neck to allow for proper healing of cervical injuries. Any movement could jeopardize the stability of the injury.
Choice D Reason:
Removing the vest daily to inspect the client's skin integrity is incorrect. The halo vest should not be removed frequently as it is meant to provide continuous immobilization. Skin integrity can be monitored by checking the areas around the vest without removing it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Administer intravenous pain medication
Administering intravenous pain medication is crucial for managing pain in burn patients. Pain management is essential to ensure the patient's comfort and to prevent complications such as shock. However, while important, it is not the immediate priority in this scenario. The primary concern should be assessing and securing the airway, especially given the location of the burns on the face and chest, which could indicate potential inhalation injuries.
Choice B: Draw blood for a complete blood cell (CBC) count
Drawing blood for a CBC count is important for assessing the patient's overall health and identifying any potential complications such as infection or anemia. However, this action is not the immediate priority. The nurse must first ensure that the patient's airway is clear and that there are no life-threatening conditions that need immediate attention.
Choice C: Inspect the mouth for signs of inhalation injuries
Inspecting the mouth for signs of inhalation injuries is the priority action. Burns to the face and chest can lead to inhalation injuries, which can cause airway obstruction and respiratory distress. Early identification and management of inhalation injuries are critical to prevent respiratory failure. Signs of inhalation injury may include soot around the mouth or nose, singed nasal hairs, and difficulty breathing. Ensuring the airway is clear and managing any inhalation injuries takes precedence over other actions.
Choice D: Insert an indwelling urinary catheter
Inserting an indwelling urinary catheter can be important for monitoring urine output, which is a key indicator of renal function and fluid balance in burn patients. However, this action is not the immediate priority. The nurse must first address any potential airway issues before proceeding with other interventions.
Correct Answer is C
Explanation
Choice A: Palpitations
Palpitations, or the sensation of a rapid or irregular heartbeat, can occur in various heart conditions, including left heart failure. However, they are not the most common or specific symptom of left heart failure. Palpitations can be caused by arrhythmias, anxiety, or other cardiac issues. In the context of left heart failure, the heart's inability to pump blood effectively leads to fluid buildup in the lungs, causing shortness of breath, which is a more direct and common manifestation.
Choice B: Peripheral edema
Peripheral edema, or swelling in the legs and ankles, is more commonly associated with right-sided heart failure. In right-sided heart failure, the heart's right ventricle fails to pump blood efficiently, leading to fluid accumulation in the body's extremities. While peripheral edema can occur in left heart failure, it is not as common as shortness of breath. Left heart failure primarily affects the lungs, leading to pulmonary congestion and shortness of breath.
Choice C: Shortness of breath
Shortness of breath, or dyspnea, is the hallmark symptom of left heart failure. When the left side of the heart fails to pump blood effectively, blood backs up into the pulmonary veins, causing fluid to leak into the lungs. This results in pulmonary congestion and difficulty breathing. Patients with left heart failure often experience shortness of breath during physical activity, while lying down (orthopnea), or waking up at night (paroxysmal nocturnal dyspnea). This symptom is a direct consequence of the heart's reduced ability to manage blood flow and is a key indicator of left heart failure.
Choice D: Chest pain
Chest pain can be a symptom of various cardiac conditions, including coronary artery disease, myocardial infarction (heart attack), and angina. While chest pain can occur in heart failure, it is not the most common manifestation of left heart failure. The primary issue in left heart failure is the heart's inability to pump blood effectively, leading to fluid buildup in the lungs and shortness of breath. Chest pain is more typically associated with ischemic heart conditions rather than heart failure itself.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today