A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Remove the vest daily to inspect the client’s skin integrity.

Check that the halo jacket is snug against the client’s skin.

Provide range of motion to the client’s neck.

Monitor the client for an elevated temperature.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.

Choice B rationale

The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.

Choice C rationale

Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.

Choice D rationale

Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.

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Correct Answer is C

Explanation

Choice A rationale

Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.

Choice B rationale

Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.

Choice C rationale

Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.

Choice D rationale

Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.

A. Vitamin B supplements. B. Iron supplements. C. Vitamin B12 injections. D. Blood transfusions.

Correct Answer is C

Explanation

Choice A rationale

Vitamin B supplements are not sufficient for treating pernicious anemia, as the condition involves an inability to absorb vitamin B12 from the gastrointestinal tract.

Choice B rationale

Iron supplements are not the primary treatment for pernicious anemia, which is specifically caused by a deficiency in vitamin B1289.

Choice C rationale

Vitamin B12 injections are the correct treatment for pernicious anemia. These injections bypass the gastrointestinal tract and provide the necessary vitamin B12 directly into the bloodstream.

Choice D rationale

Blood transfusions are not typically required for the treatment of pernicious anemia unless there is severe anemia or other complications.

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A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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