A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
A The purpose of this device is to immobilize the cervical spine."
B The purpose of this device is to allow for neck movement during the healing process."
C "Apply talcum powder under the vest to limit friction."
D Tum the screws on the device once each day."
The Correct Answer is A
Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.
Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.
Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.
Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Urinary output is also an important assessment in clients with a C3 spinal cord injury because it helps monitor for urinary retention and potential complications but it is not a priority compared to assessing the respiratory function of this client.
Choice B Rationale: Blood pressure is important to monitor but may not be the top priority assessment in this context.
Choice C Rationale: The nurse should prioritize counting respirations for a client with a C3 spinal cord injury, as this level of injury affects the phrenic nerve that innervates the diaphragm. The client may have difficulty breathing and require mechanical ventilation.
Choice D Rationale: Bowel sounds are important but may not be the priority assessment in this case.
Correct Answer is ["A","B","D"]
Explanation
Choice A Rationale: A weakened gag reflex is a potential complication of a cervical spinal cord injury and can lead to difficulties in swallowing and increased risk of aspiration.
Choice B Rationale: Hyperthermia can occur as a result of autonomic dysfunction associated with spinal cord injuries, especially when the injury is at a high cervical level.
Choice C Rationale: Absence of bowel sounds is not typically associated with cervical spinal cord injuries but may be seen in lower spinal cord injuries.
Choice D Rationale: Hypotension is a potential complication due to impaired autonomic regulation in cervical spinal cord injuries.
Choice E Rationale: Polyuria is not typically associated with cervical spinal cord injuries but may occur in cases of lower spinal cord injuries affecting bladder function.
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