A patient has a new order for a thoraco-lumbo-sacral orthosis (TLSO) to help support and stabilize her spine. What are the nursing priorities when caring for this patient? (Select all that apply)
Ensuring proper fit of the brace
How patient sleeps with the brace on
Monitor patient breathing
Patient education and family about the brace’s purpose and care
Skin integrity
Correct Answer : A,C,D,E
Choice A reason: Ensuring proper fit of the TLSO is critical to stabilize the spine effectively, preventing further injury. An ill-fitting brace can cause misalignment, pressure sores, or reduced efficacy, as it fails to immobilize the thoracolumbar region, making this a key nursing priority.
Choice B reason: How the patient sleeps with the brace is not a primary nursing priority. While comfort during sleep matters, the TLSO is typically worn as prescribed, and sleep position is secondary to ensuring fit, breathing, education, and skin care, making this choice incorrect.
Choice C reason: Monitoring breathing is essential, as a TLSO can restrict chest expansion, potentially reducing tidal volume and causing respiratory distress. Nurses must assess respiratory rate and oxygen saturation to ensure the brace does not compromise ventilation, making this a critical priority.
Choice D reason: Educating the patient and family about the TLSO’s purpose and care ensures compliance and proper use. Understanding how to wear, clean, and adjust the brace prevents complications like skin breakdown or ineffective stabilization, making this a key nursing responsibility.
Choice E reason: Skin integrity is a priority, as prolonged brace use can cause pressure ulcers or irritation. Nurses must inspect skin under the TLSO regularly, ensuring proper padding and hygiene to prevent breakdown, especially in immobile patients, making this a critical care aspect.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Antisocial personality disorder involves disregard for others’ rights, impulsivity, and manipulation, not indecision or need for reassurance. These individuals act independently, often violating social norms, and lack the excessive reliance on others seen in the client’s behavior, making this choice incorrect for the described manifestations.
Choice B reason: Avoidant personality disorder is characterized by social withdrawal due to fear of rejection, not indecision or constant reassurance-seeking. While avoidant individuals may lack confidence, their primary issue is social anxiety, not reliance on others for decision-making, making this choice incorrect for the client’s symptoms.
Choice C reason: Schizoid personality disorder involves emotional detachment and preference for solitude, not indecision or reassurance-seeking. These individuals are indifferent to others’ input and rarely seek guidance, contrasting with the client’s dependent behavior, making this choice incorrect for the described manifestations.
Choice D reason: Dependent personality disorder is marked by excessive reliance on others for decision-making and constant need for reassurance due to fear of abandonment and low self-efficacy. The client’s inability to decide and need for validation align with this disorder’s core features, involving submissive behavior and anxiety, making this the correct choice.
Correct Answer is D
Explanation
Choice A reason: Limiting alcohol intake reduces cancer risk, as excessive alcohol is linked to cancers of the liver, mouth, and esophagus due to DNA damage from acetaldehyde, a metabolite. This statement reflects a correct understanding of cancer prevention, aligning with evidence-based guidelines, so no additional teaching is needed.
Choice B reason: Wearing sunscreen daily protects against ultraviolet radiation, a primary cause of skin cancers like melanoma by preventing DNA mutations in skin cells. This statement shows appropriate knowledge of cancer prevention, consistent with recommendations, and does not require further education from the nurse.
Choice C reason: Daily walking promotes physical activity, which reduces cancer risk by regulating hormones like insulin and estrogen, linked to breast and colorectal cancers. This statement indicates correct understanding of lifestyle measures for cancer prevention, aligning with health guidelines, so no additional information is needed.
Choice D reason: Increasing red meat intake, especially processed or charred meat, raises cancer risk, particularly colorectal cancer, due to carcinogenic compounds like heterocyclic amines formed during cooking. This statement indicates a misunderstanding, as reducing red meat is recommended, requiring the nurse to provide corrective education.
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