A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
Encourage flexion and extension of the neck.
Reposition the client using a turning sheet.
Assess the pin sites for infection once every other day.
Tighten the screws on the halo device one-quarter turn every 48 hr.
The Correct Answer is B
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Visual analog scales rely on the child's ability to comprehend and interpret visual cues, which may be challenging for a cognitively impaired toddler.
B. FACES scales require the child to identify their pain level based on facial expressions, which may also be challenging for a cognitively impaired toddler.
C. FLACC (Face, Legs, Activity, Cry, Consolability) scales are specifically designed for non-verbal or cognitively impaired individuals, assessing pain based on observable behaviors such as facial expression, leg movement, activity level, cry, and ability to be consoled.
D. CRIES scales are primarily used for assessing pain in newborns and infants and may not be as applicable for a cognitively impaired toddler.
Correct Answer is D
Explanation
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
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