A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?
Place the client in protective isolation.
Initiate the use of a PCA pump for pain control.
Keep the head of the bed at a 30° angle.
Reposition the client by log rolling every-4 hr.
The Correct Answer is D
A. Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
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Related Questions
Correct Answer is C
Explanation
A. Teaching the primary caregiver is an important component of post-discharge planning, but the focus of rehabilitative care is on the client’s functional recovery, mobility, and independence rather than solely caregiver instruction.
B. Rehabilitation supports recovery, but effective outcomes require early initiation. Planning and interventions often start during hospitalization to address mobility deficits, prevent complications such as pressure injuries or deconditioning, and prepare the client for a safe transition to the next level of care.
C. Rehabilitative care begins with hospital admission, when the healthcare team evaluates the client’s physical and functional status, develops individualized goals, and initiates early interventions. Early rehabilitation is supported by research to improve mobility, reduce length of stay, and optimize long-term functional outcomes.
D. Rehabilitation is not confined to long-term care facilities; it can occur in hospitals, outpatient clinics, specialized rehab centers, and at home, depending on the client’s needs and recovery trajectory.
Correct Answer is A
Explanation
A. Placing a bath seat in the shower is a safety measure to prevent falls while bathing. This statement indicates an understanding of the importance of bathroom safety.
B. Placing an area rug at the entry of the bathroom can actually increase the risk of falls, as rugs can be tripping hazards. This statement does not demonstrate an understanding of home safety.
C. Keeping the walker at the end of the bed is a good practice for easy access, but it doesn't specifically address fall prevention in the home.
D. Keeping the fluorescent ceiling light on at night can provide better visibility and reduce the risk of tripping, but it doesn't address specific fall prevention measures elsewhere in the home.
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