A nurse is providing care for a client with a halo device. The client has developed skin breakdown and irritation around the pin sites. Which intervention is most appropriate for the nurse to implement to prevent further skin complications?

Ensure that the vest supporting the halo device is snug and properly aligned.

Apply a thick layer of zinc oxide cream around the pin sites.

Pad the areas of skin breakdown with foam dressing to reduce friction and pressure.

Loosen the halo device to reduce pressure on the skin.

Answer and Explanation

The Correct Answer is C

A. While ensuring proper alignment is important, it does not address the existing skin breakdown and irritation.
B. Applying zinc oxide cream may not be appropriate as it can trap moisture, potentially worsening the skin condition around pin sites.
C. Padding the areas of skin breakdown with foam dressing is an appropriate intervention as it can provide cushioning, reduce friction, and protect the skin from further injury.
D. Loosening the halo device could compromise the stabilization it provides and may not effectively address skin integrity issues.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Edema of the ear canal is a common symptom of external otitis, indicating inflammation and infection in the area.
B. Purulent drainage from the ear canal often signifies bacterial infection and is a key symptom to monitor.
C. Burning in the ear canal can occur due to inflammation and is a common complaint in external otitis.
D. Pain when moving the auricle is a classic symptom of external otitis, indicating irritation or inflammation of the external ear.
E. Tenderness of the external ear is a common finding in external otitis and should be monitored as it indicates inflammation and potential infection.

A. Encouraging the client to perform deep breathing exercises. B. Elevating the head of the bed. C. Administering a sedative. D. Monitoring intracranial pressure (ICP).

Correct Answer is D

Explanation

A. Encouraging deep breathing exercises may help with respiratory function but does not address the immediate risks associated with increased ICP.
B. Elevating the head of the bed can help reduce ICP; however, the priority intervention is to closely monitor ICP to identify any changes in the client's condition.
C. Administering a sedative may be appropriate, but it is not as critical as monitoring ICP in a client with Cushing's Triad, where altered consciousness and respiratory changes may be present.
D. Monitoring ICP is crucial in this situation, as Cushing's Triad indicates a potential increase in ICP, and timely interventions can prevent further complications.

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A nurse is providing care for a client with a halo device. The client has developed skin breakdown and irritation around the pin sites. Which intervention is most appropriate for the nurse to implement to prevent further skin complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client that has been diagnosed with external otitis. Which of the following clinical symptoms should the nurse be monitoring?

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is caring for a client who is experiencing Cushing's Triad following a depressed skull fracture. In addition to administering appropriate medications, which of the following nursing interventions should the nurse prioritize for this client?

Correct Answer is D

Explanation

A nurse is assessing a client with autonomic dysreflexia. The nurse correlates which clinical manifestations to autonomic dysreflexia in a client with a spinal cord injury?

A nurse is caring for a client who has quadriplegia due to a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. What should the nurse prioritize as the initial action?

A client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse should initiate which of the following interventions?

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

A nurse is caring for a client in an induced coma for increased intracranial pressure (ICP). What should the nurse assess next to determine this client's cerebral function?

A nurse is discussing discharge instructions to a client with a lumbar herniated disk and is prescribed a conservative treatment. The nurse provides instructions based on this treatment plan and suggests which of the following.

A client who swims several times a week asks the nurse, "Why are ears prone to frequent infection?" What is the nurse's best response?