A nurse is contributing to the plan of care for a client who has a halo vest after experiencing a cervical fracture 8 hr ago. Which of the following interventions should the nurse recommend including in the plan?
Reposition the client in bed using the halo ring.
Turn the client every 4 hr.
Loosen the screws while cleansing the pin sites.
Change the sheepskin lining under the device weekly.
The Correct Answer is A
A. When caring for a client with a halo vest after a cervical fracture, it's essential to maintain spinal alignment and prevent further injury. Repositioning the client using the halo ring ensures that the cervical spine remains immobilized during movement, thereby reducing the risk of additional damage. This method provides controlled movement while preserving the integrity of the spinal column.
B. This is incorrect. While frequent turning is necessary to prevent complications such as pressure injuries, turning every 2 hours (not 4) is the standard for immobile clients.
C. Loosen the screws while cleansing the pin sites: This is incorrect as loosening the screws can compromise the stability of the halo vest. Pin site care should be done carefully without altering the tension of the screws.
D. Change the sheepskin lining under the device weekly: This is not frequent enough for proper hygiene and skin care; the lining should be checked more regularly and changed as needed to maintain skin integrity and comfort.
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Related Questions
Correct Answer is C
Explanation
A. Monthly vitamin B12 injections: This is incorrect as vitamin B12 injections are not associated with osteoporosis. They are often used to address vitamin B12 deficiency, which is not a direct risk factor for osteoporosis.
B. History of kidney stones: This is incorrect because while kidney stones can be associated with calcium metabolism issues, they are not a primary risk factor for osteoporosis.
C. Long-term use of prednisone: This is correct as long-term use of corticosteroids like prednisone can lead to decreased bone density and increased risk of osteoporosis due to their impact on bone metabolism.
D. Congenital heart murmur: This is incorrect as a congenital heart murmur is not related to the development of osteoporosis.
Correct Answer is D
Explanation
A. Offer snacks that are high in sodium: This is incorrect as high sodium intake can exacerbate heart failure by increasing fluid retention and worsening symptoms.
B. Place the head of the client's bed flat: This is incorrect because elevating the head of the bed helps reduce shortness of breath and improves comfort in heart failure patients.
C. Monitor the client's weight once per week: This is incorrect; daily weight monitoring is recommended to detect fluid retention or loss, which can be critical in managing heart failure.
D. Provide rest periods throughout the day: This is correct as providing rest periods helps manage fatigue and reduce the workload on the heart, which is important in heart failure management.
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