A nurse is contributing to the care plan for a client who has a halo vest following a cervical fracture 8 hours ago. Which intervention should the nurse recommend for inclusion in the plan?
Loosen the screws while cleaning the pin sites.
Turn the client every 4 hours.
Change the sheepskin lining under the device weekly.
Reposition the client in bed using the halo ring.
The Correct Answer is C
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to prepare for a colonoscopy by cleaning out the colon, drinking full liquids until 6 hours before the procedure may not be recommended. The colon needs to be empty to allow the doctor to view it clearly during the colonoscopy. Therefore, this choice is incorrect.
Choice B rationale
Moderate sedation is often used during a colonoscopy. This means you’ll be relaxed and somewhat drowsy, but you’ll still be awake. You might not remember much about the actual procedure because of the sedative. Therefore, this choice is correct.
Choice C rationale
During a colonoscopy, you will likely start by lying on your left side. However, you may be asked to adjust your position during the procedure to allow the doctor to better examine certain parts of your colon. Therefore, this choice is incorrect.
Choice D rationale
Warming the liquid bowel preparation before drinking it is not typically recommended. The bowel preparation involves drinking a solution that helps clear out the colon, but it doesn’t need to be warmed. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
Choice A rationale
Participating in reminiscence therapy can be beneficial for patients with Alzheimer’s disease. This therapy involves discussing past experiences and life events, which can help improve mood, enhance communication, and maintain self-identity.
Choice B rationale
Raising all four side rails on a patient’s bed is not recommended. This can be considered a form of restraint and can increase the risk of injury if the patient attempts to climb over the rails. It’s important to promote a safe environment while respecting the patient’s rights.
Choice C rationale
Alternating the patient’s daily routine can be confusing and disorienting for individuals with Alzheimer’s disease. Maintaining a consistent routine can provide a sense of security and predictability.
Choice D rationale
Keeping the lights dimmed is not specifically beneficial for patients with Alzheimer’s disease. Adequate lighting can help prevent falls and other accidents. However, creating a calm and quiet environment can help reduce agitation.
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