A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?
"You should not have sexual intercourse while the monitor is in place."
"You can bathe while wearing the electrodes."
"You should remove the electrodes when you go to bed."
"You will need to record daily activities in a diary."
The Correct Answer is D
A. "You should not have sexual intercourse while the monitor is in place.": This is incorrect because sexual activity is generally not restricted while wearing a Holter monitor. The main focus is on ensuring the monitor remains attached.
B. "You can bathe while wearing the electrodes.": This is incorrect because bathing or getting the electrodes wet can interfere with the monitor's functionality and potentially lead to inaccurate readings.
C. "You should remove the electrodes when you go to bed.": This is incorrect because the electrodes should remain in place for the full 24-hour period to ensure continuous monitoring.
D. "You will need to record daily activities in a diary.": This is correct as recording activities in a diary is crucial for correlating symptoms with the Holter monitor data.
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Related Questions
Correct Answer is A
Explanation
A. When caring for a client with a halo vest after a cervical fracture, it's essential to maintain spinal alignment and prevent further injury. Repositioning the client using the halo ring ensures that the cervical spine remains immobilized during movement, thereby reducing the risk of additional damage. This method provides controlled movement while preserving the integrity of the spinal column.
B. This is incorrect. While frequent turning is necessary to prevent complications such as pressure injuries, turning every 2 hours (not 4) is the standard for immobile clients.
C. Loosen the screws while cleansing the pin sites: This is incorrect as loosening the screws can compromise the stability of the halo vest. Pin site care should be done carefully without altering the tension of the screws.
D. Change the sheepskin lining under the device weekly: This is not frequent enough for proper hygiene and skin care; the lining should be checked more regularly and changed as needed to maintain skin integrity and comfort.
Correct Answer is C
Explanation
A. Elevate the head of the bed 45° before starting the CPM device: This is not necessarily required and may not be appropriate based on the specific needs of the client or the setup of the CPM device.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect as the CPM device should be properly aligned with the joint's neutral position to avoid discomfort and ensure effective movement.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct as proper alignment ensures that the device functions effectively and helps in the controlled movement of the knee joint.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect as the degree of flexion should be adjusted according to the provider’s orders, not based on the client’s tolerance alone.
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