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 D

Explanation

A. Monitoring glucose levels may be necessary, as pheochromocytoma can cause hyperglycemia, but it is not the immediate priority.
B. A CT scan may be part of the diagnostic process to locate the adrenal tumor, but the priority is to control blood pressure first due to the risk of severe hypertensive crisis.
C. Serum calcium levels are not directly related to pheochromocytoma and are not a priority action.
D. Monitoring blood pressure is critical, as pheochromocytoma causes episodes of severe hypertension, which can lead to life-threatening complications.

A. Encourage fluid intake at and between meals. B. Cleanse the perineum from back to front. C. Offer the client the bedpan every 2 hours. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is A

Explanation

A. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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