A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching?
Give each screw a quarter turn daily using the wrench provided.
Apply powder liberally under the chest portion of the halo fixator device.
Avoid the use of straws when drinking liquids.
Place a small pillow under the head while lying supine.
The Correct Answer is D
Rationale:
A. Give each screw a quarter turn daily using the wrench provided: Clients should never adjust or tighten the halo device screws themselves. Only trained medical professionals should handle adjustments to avoid misalignment or injury to the cervical spine.
B. Apply powder liberally under the chest portion of the halo fixator device: Powder can cake and irritate the skin or lead to moisture buildup, increasing the risk of skin breakdown or infection. The skin under the vest should be kept clean and dry, not powdered.
C. Avoid the use of straws when drinking liquids: Clients can safely use straws to drink fluids while wearing a halo device. There is no contraindication for using a straw, and it may actually make drinking easier.
D. Place a small pillow under the head while lying supine: Using a small pillow supports neck alignment and promotes comfort without compromising the stability of the halo device. This is an appropriate and recommended practice during rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. This area is the lateral side of the the heel and is more commonly affected by arterial ulcers or pressure injuries. It is not the typical location for ulcers caused by venous insufficiency.
B. This area is the area on the tip of toes and is not a typical site for venous ulcers. Ulcers in this location are commonly arterial or diabetic ulcers.
C. This area is the area on the sole of the feet at the base of the big toe and is not a typical site for venous ulcers.
D. This area is the medial malleolus, just above the inner ankle, which is the most common site for venous ulcers. Chronic venous insufficiency leads to venous stasis and increased pressure in this region, causing skin breakdown and ulceration.
Correct Answer is D
Explanation
Rationale:
A. Decreased calcium levels: Hypocalcemia may cause neuromuscular symptoms such as tetany or tingling but is not associated with exophthalmos (protruding eyes). Calcium imbalance does not typically cause changes in eye appearance.
B. Decreased somatotropin levels: Somatotropin (growth hormone) deficiency may lead to growth delay or reduced muscle mass, but it is not associated with changes in orbital appearance. Protruding eyes are unrelated to growth hormone levels.
C. Increased glucose levels: Elevated glucose is characteristic of diabetes mellitus and may lead to complications like neuropathy or retinopathy, but it does not cause eye protrusion.
D. Increased T4 levels: Elevated thyroxine (T4) is seen in hyperthyroidism, particularly in Graves' disease, which is strongly associated with exophthalmos. The protrusion results from inflammation and edema of orbital tissues, a hallmark of this thyroid disorder.
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