The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Soak the pin sites with alcohol pads

Remove the vest when bathing the patient

Assess the chest and back for skin breakdown

Assess pin sites frequently for signs of infection

Tape a halo wrench to the vest for emergencies

Answer and Explanation

Correct Answer : C,D,E

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

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Correct Answer is B

Explanation

Choice A reason:

Young adults ages 12-20 are at risk for spinal cord injuries due to sports and recreational activities. However, the highest risk group for spinal cord injuries, particularly from activities such as motor vehicle accidents and risky behaviors, is young men ages 16-30.

Choice B reason:

Young men ages 16-30 are the highest risk group for spinal cord injuries. This population is more likely to engage in high-risk activities such as driving, contact sports, and recreational activities that can lead to spinal cord injuries. Therefore, they would benefit most from targeted prevention education.

Choice C reason:

Children ages 2-15 are at risk for spinal cord injuries, particularly from falls and accidents. However, their risk is lower compared to the young adult male population. Education for this group is important but not as critical as for young men.

Choice D reason:

Elderly people ages 60 and up are at risk for spinal cord injuries, primarily from falls. While prevention education is important for this group, they are not the highest risk population compared to young men ages 16-30.

A. Decorticate posturing B. Flexion withdrawal C. Localization of pain D. Decerebrate posturing

Correct Answer is D

Explanation

Choice A reason:

Decorticate posturing involves abnormal flexion of the arms towards the chest and extension of the legs. This posture indicates damage to the corticospinal tract at the level of the diencephalon. The described response does not match decorticate posturing.

Choice B reason:

Flexion withdrawal is a response to painful stimuli where the patient pulls away or flexes the affected limb. This is a less severe response than posturing and does not match the description provided in the scenario.

Choice C reason:

Localization of pain refers to the patient's ability to purposefully move a hand to the site of a painful stimulus, indicating higher brain function. The described response of arm and leg extension with pronation does not fit this description.

Choice D reason:

Decerebrate posturing is characterized by extension of the arms and legs, pronation of the arms, and plantar flexion. This posture indicates severe brainstem damage and is consistent with the described response.

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The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

Correct Answer is B

Explanation

A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Correct Answer is D

Explanation

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