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 ["A","B","C","D","E"]
Explanation
Choice A Reason:
Cancer is a significant risk factor for DIC, particularly certain types of leukemia and metastatic cancers. Cancer can trigger DIC through the release of procoagulant substances from tumor cells, leading to widespread clotting and subsequent bleeding. The hypercoagulable state associated with malignancies increases the risk of thrombotic events, which can precipitate DIC. Patients with advanced cancer are particularly susceptible due to the aggressive nature of the disease and the body's inflammatory response.
Choice B Reason:
Sepsis is one of the most common causes of DIC. Sepsis triggers a systemic inflammatory response that activates the coagulation cascade, leading to the formation of microthrombi throughout the vasculature. This widespread clotting depletes clotting factors and platelets, resulting in a paradoxical increase in bleeding risk. The severity of sepsis correlates with the likelihood of developing DIC, making early recognition and treatment of sepsis crucial.
Choice C Reason:
Trauma can lead to DIC through extensive tissue injury and the release of tissue factor into the bloodstream. Severe trauma, such as that from major accidents or surgeries, can overwhelm the body's hemostatic mechanisms, leading to uncontrolled clotting and bleeding. The inflammatory response to trauma further exacerbates the coagulation process, increasing the risk of DIC. Prompt management of traumatic injuries and monitoring for signs of DIC are essential in these patients.
Choice D Reason:
Pregnancy complications such as placental abruption, amniotic fluid embolism, and severe preeclampsia can precipitate DIC. These conditions cause significant endothelial damage and the release of procoagulant substances, triggering the coagulation cascade. The physiological changes during pregnancy, including increased blood volume and hypercoagulability, further predispose pregnant women to DIC. Early intervention and management of pregnancy-related complications are vital to prevent DIC.
Choice E Reason:
Blood transfusion reactions can lead to DIC through immune-mediated mechanisms. Incompatible blood transfusions can cause hemolysis and the release of procoagulant substances, initiating the coagulation cascade. The resulting widespread clotting and consumption of clotting factors can lead to bleeding complications. Careful matching of blood products and monitoring for transfusion reactions are critical to prevent DIC in transfusion recipients.
Correct Answer is B
Explanation
Choice A Reason:
Improved blood flow to surrounding tissues is generally a desired outcome of treating an aneurysm, not a complication. When an aneurysm is successfully treated, the goal is to restore normal blood flow and prevent the aneurysm from rupturing. Improved blood flow indicates that the treatment was effective and that the risk of complications has been minimized.
Choice B Reason:
Rupture leading to severe internal bleeding is a significant potential complication of a treated aneurysm. Even after treatment, there is a risk that the aneurysm could rupture, especially if the treatment was not entirely successful or if the aneurysm was particularly large or complex. A rupture can lead to life-threatening internal bleeding and requires immediate medical attention. This is why ongoing monitoring and follow-up care are crucial for patients who have had an aneurysm treated.
Choice C Reason:
Decreased risk of blood clot formation is another desired outcome rather than a complication. Treating an aneurysm often involves measures to prevent blood clots, such as using anticoagulant medications. A successful treatment should reduce the risk of clot formation, which can otherwise lead to complications like stroke or embolism.
Choice D Reason:
Reduced risk of infection is also a desired outcome of aneurysm treatment. Infection can be a complication of any surgical procedure, including those used to treat aneurysms. However, with proper surgical techniques and post-operative care, the risk of infection can be minimized. Therefore, a reduced risk of infection is not a complication but rather an indication of successful treatment and good medical practice.
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