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
Question 1: The correct answer is Choice c. Perform developmental testing for delays.
Lead poisoning can lead to cognitive, behavioral, and developmental impairments, making developmental testing crucial for assessing potential delays and planning interventions. Developmental testing allows healthcare providers to identify any areas of concern early on, enabling them to implement appropriate interventions to support the child's development and mitigate the effects of lead poisoning.
Choice A rationale: Obtaining a stool specimen for lead levels is not the appropriate action in this scenario. Lead poisoning is typically assessed through blood lead levels, not stool specimens. Stool specimens are more commonly used for assessing gastrointestinal issues or infections rather than lead levels.
Choice B rationale: Initiating a low-iron diet for lead absorption is not recommended. Iron deficiency can actually increase lead absorption in the body, so reducing iron intake could potentially exacerbate the issue. Instead, ensuring an adequate intake of iron-rich foods may be beneficial for overall health but is not a primary intervention for lead poisoning.
Choice D rationale: Inspecting the skin for discoloration is not a relevant action for assessing lead poisoning. While lead poisoning can manifest in various symptoms, skin discoloration is not typically associated with lead exposure. Other signs and symptoms such as cognitive, behavioral, and developmental impairments are more indicative of lead poisoning.
Correct Answer is B
Explanation
Choice A rationale
Aspartame is a low-calorie sweetener used in place of sugar. However, it is not recommended for individuals with phenylketonuria (PKU) because it contains phenylalanine, an amino acid that individuals with PKU cannot metabolize properly.
Choice B rationale
Individuals with PKU are advised to avoid foods containing milk products. This is because milk and other
dairy products contain phenylalanine, which individuals with PKU cannot metabolize properly. Instead, they are advised to consume a diet low in protein and supplemented with a phenylalanine-free medical formula.
Choice C rationale
Increasing protein consumption is not recommended for individuals with PKU. This is because protein-rich foods often contain phenylalanine, an amino acid that individuals with PKU cannot metabolize properly.
Instead, they are advised to consume a diet low in protein and supplemented with a phenylalanine-free medical formula.
Choice D rationale
Limiting foods high in iron is not specifically related to the dietary management of PKU. Individuals with PKU primarily need to avoid foods high in phenylalanine.
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