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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Feeling fatigued is not indicative of a therapeutic response; rather, patients should experience increased energy levels with appropriate therapy.
B. Decreased thyroxine levels are not the primary goal of levothyroxine therapy, which aims to normalize thyroid hormone levels in the body.
C. Decreased thyroid-stimulating hormone (TSH) levels indicate that the body is responding well to levothyroxine, as TSH production decreases when thyroid hormone levels are adequate.
D. Bradycardia and hypotension are not desired effects of levothyroxine and indicate potential under-treatment or other issues rather than a therapeutic response.
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