A nurse is caring for a client who has an upper cervical spinal cord injury and a halo device. Which of the following actions should the nurse take?

Ensure one finger can be inserted between the vest and client's skin.

Use the halo device to turn the client in bed.

Use a pen to itch under the vest

Tighten halo pins when loose.

Answer and Explanation

The Correct Answer is A

A. Ensure one finger can be inserted between the vest and client's skin: Allowing one finger’s space prevents skin breakdown while maintaining proper immobilization. This ensures the vest is snug enough to stabilize the cervical spine but not so tight that it causes pressure ulcers or discomfort.

B. Use the halo device to turn the client in bed: The halo device is rigid and should never be used as a lever to move the client, as this can cause cervical spine injury. Turning and repositioning should be done by supporting the head, neck, and torso manually, not by pulling on the device.

C. Use a pen to itch under the vest: Inserting objects under the vest can damage the skin and increase the risk of infection or pressure injuries. Clients should be taught to relieve itching by gentle tapping or using approved tools outside the vest.

D. Tighten halo pins when loose: Halo pins should only be adjusted by a healthcare provider. Tightening pins independently can cause skull fractures, nerve injury, or increased pain, making this action unsafe for nursing practice.

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Correct Answer is C

Explanation

A. "The best way to treat your cancer is chemotherapy.": This response is directive and does not explore the client’s perspective or provide an opportunity for discussion. It may make the client feel dismissed and does not promote therapeutic communication or informed decision-making.

B. “I have never heard of any holistic treatment that is effective”: This statement invalidates the client’s preference and can damage trust. It focuses on the nurse’s opinion rather than understanding the client’s beliefs, limiting collaborative care and shared decision-making.

C. "Tell me what you know about chemotherapy.": This response encourages the client to share their knowledge and concerns, allowing the nurse to clarify misconceptions and provide education. It fosters an open, therapeutic dialogue and helps the client make an informed choice about treatment options.

D. "You should ask your provider about your plan.": While consulting the provider is important, this response shifts responsibility away from the nurse and does not address the client’s concerns directly. It misses the opportunity to assess understanding and provide immediate support or education.

A. Elevate the extremity above the heart. B. Use padded splints. C. Reposition the client every 2 hr. D. Apply a sequential compression device.

Correct Answer is B

Explanation

A. Elevate the extremity above the heart: Elevating the leg helps reduce edema but does not prevent footdrop, which is caused by weakness or paralysis of the ankle dorsiflexor muscles following a CVA. Elevation alone will not maintain proper ankle positioning.

B. Use padded splints: Padded footboards or splints help maintain the ankle in a neutral position and prevent plantar flexion, which reduces the risk of footdrop. This intervention supports proper alignment and promotes functional positioning during recovery.

C. Reposition the client every 2 hr: Repositioning prevents pressure injuries and promotes circulation but does not specifically address the muscular imbalance that leads to footdrop. While important for overall care, it is not the primary intervention for this complication.

D. Apply a sequential compression device: Sequential compression devices are used to prevent venous thromboembolism, not footdrop. They promote blood flow in the lower extremities but do not maintain ankle dorsiflexion or prevent contractures.

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A nurse is caring for a client who has an upper cervical spinal cord injury and a halo device. Which of the following actions should the nurse take?

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