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.
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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Related Questions
Correct Answer is D
Explanation
Choice D rationale
Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.
Choice A rationale
Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.
Choice B rationale
Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.
Choice C rationale
Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.
Correct Answer is A
Explanation
Choice A rationale
Lying on the left side can help minimize the effects of reflux during sleep. This position helps keep the stomach contents lower than the esophagus, reducing the likelihood of acid reflux.
Choice B rationale
Lying on the right side can increase the risk of acid reflux. This position allows the stomach contents to flow more easily into the esophagus, exacerbating reflux symptoms.
Choice C rationale
Sleeping on the back with the head flat can worsen reflux symptoms. This position allows stomach acid to flow back into the esophagus more easily, increasing the risk of reflux.
Choice D rationale
Sleeping on the stomach with the head flat is not recommended for clients with GERD. This position can increase pressure on the stomach, promoting acid reflux into the esophagus.
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