A nurse is caring for a client who is postoperative 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
Assess the pin sites for injection once every other day
Reposition the client using a turning sheet
Tighten the screw on the halo device once-quarter turn every 48 hr. .
The Correct Answer is C
Choice A rationale
Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.
Choice B rationale
Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.
Choice C rationale
Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.
Choice D rationale
Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Children with autism spectrum disorder often thrive on routines and predictability. Varying daily routines can be distressing and may lead to increased anxiety.
Choice B rationale
Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.
Choice C rationale
This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.
Choice D rationale
Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.
Correct Answer is A
Explanation
Choice A rationale
Tachypnea, or rapid breathing, is a common clinical manifestation of heart failure in children. This occurs because the heart is unable to pump enough blood to meet the body’s needs, causing fluid to back up into the
lungs and leading to shortness of breath and rapid breathing.
Choice B rationale
Contrary to increased appetite, children with heart failure often experience a decrease in appetite or difficulty feeding. This is due to increased energy expenditure and early satiety caused by abdominal distension from hepatomegaly or ascites.
Choice C rationale
Tremors are not typically associated with heart failure. They could be a sign of other neurological conditions, side effects of certain medications, or anxiety.
Choice D rationale
Bradycardia, or a slower than normal heart rate, is not typically a symptom of heart failure. In fact, tachycardia, or a faster than normal heart rate, is more commonly seen in heart failure as the heart tries to compensate for its reduced ability to pump blood.
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