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. Warming goat's milk before feeding does not address the issue of nutritional adequacy or the potential allergenicity of goat's milk.
B. Soy milk may not be suitable for infants under 12 months old due to potential allergenicity and nutritional concerns.
C. Commercially prepared infant formula is the most appropriate option for infants who are having difficulty with breastfeeding or require an alternative to breast milk.
D. Reinitiating breastfeeding may not be feasible or appropriate if the infant is already having difficulty eating.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
A. While acute glomerulonephritis can occur following certain infections such as streptococcal infections, it is less commonly associated with fever and lethargy compared to pyelonephritis.
B. Pyelonephritis is a bacterial infection of the kidneys commonly associated with fever and lethargy, especially in young children. The fever and lethargy reported by the parent, along with the urine sample obtained, suggest a concern for pyelonephritis.
C. Polycystic kidney disease typically presents later in life and is not typically associated with acute febrile illness in a 1-year-old toddler.
D. Renal scarring can occur as a complication of untreated or recurrent urinary tract infections (UTIs), particularly pyelonephritis. The presence of fever and lethargy in the child, along with the history of decreased appetite, raises concerns for a urinary tract infection that could lead to renal scarring if left untreated.
E. Nephrotic syndrome typically presents with edema, proteinuria, hypoalbuminemia, and hyperlipidemia, rather than the symptoms described in the scenario.
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