The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?
Loosen all of the connections on the vest to assess the skin
Ask about the client's ability to perform range of motion to legs
Ask how the client is able to reposition self in bed
Assess the pin sites
The Correct Answer is D
Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.
Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.
Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.
Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.
Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.
Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.
Choice D Rationale: Documenting the incident is important but should follow
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Rationale: Understanding the expected physiological changes of Alzheimer's disease can help the caregiver better cope with the client's behaviors and needs.
Choice B Rationale: Teaching actions to reduce stress is important for both the caregiver and the client, as stress can exacerbate behavioral symptoms in Alzheimer's disease.
Choice C Rationale: Referring to available community resources can provide valuable support and assistance to both the caregiver and the client.
Choice D Rationale: Identifying a social support system is essential for the caregiver to have emotional and practical support while caring for a client with Alzheimer's disease.
Choice E Rationale: While medication administration is important, it may not be the primary focus of coping strategies for the caregiver.
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