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 C
Explanation
Choice A rationale
Accepting that sexual activity will decrease does not necessarily indicate acceptance of a new altered body image. It may reflect a misunderstanding or fear about the impact of the colostomy.
Choice B rationale
Denying feelings of sadness about the ostomy does not necessarily indicate acceptance of a new altered body image. It may suggest that the patient is not fully acknowledging the emotional impact of the change.
Choice C rationale
Participating in performing ostomy care is a positive sign that the patient has accepted their new altered body image. It shows that the patient is taking an active role in their care and adapting to the change.
Choice D rationale
Preferring not to look at the stoma site does not indicate acceptance of a new altered body image. It may suggest avoidance or denial.
Correct Answer is B
Explanation
Choice A rationale
Fever is not typically a sign of fluid overload. It’s more commonly associated with a transfusion reaction, which could indicate an immune response to the transfused blood.
Choice B rationale
Dyspnea, or difficulty breathing, can be a sign of fluid overload. When the body has too much fluid, it can put pressure on the lungs, making it harder to breathe.
Choice C rationale
Pruritus, or itching, is not typically a sign of fluid overload. It may be a sign of an allergic reaction to the transfusion.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of fluid overload. In fact, tachycardia, or a fast heart rate, is more common as the heart works harder to pump the excess fluid.
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