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
- A: Riding against the flow of traffic is unsafe because it increases the likelihood of an accident. Drivers do not expect to see cyclists coming from the opposite direction and may not have enough time to react if they encounter one.
- B: Keeping the bicycle at least 3 feet from the curb is not always practical or safe. It may place the cyclist in the path of moving traffic, which can be dangerous, especially for children who may not have the experience to navigate around cars safely.
- C: Walking the bicycle through intersections is a safe practice because it allows the child to navigate the intersection without being in the path of cars, giving them time to look for oncoming traffic and proceed when it is safe.
- D: The child's feet should be able to touch the ground when seated on the bicycle. This ensures that the child can maintain balance and control of the bicycle, especially in situations where they need to stop quickly.
Correct Answer is B
Explanation
A. No head lag when pulled to a sitting position is a normal finding at 4 months of age.
B. They should not have doll's eye reflex intact, which means that their eyes move in the opposite direction of their head when turned. This reflex normally disappears by 3 months of age and its persistence may indicate brain damage.
C. The presence of tears when crying is a normal finding at 4 months of age.
D. They should also have positive Babinski reflex, which means that their toes fan out when their sole is stroked. This reflex normally disappears by 12 months of age.
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