A nurse is caring for a child who is in a halo vest for cervical traction. Which of the following actions should the nurse take?
Show the child's parent how to release tension on the bars.
Remove the vest for the child to sleep at night.
Check the child's pupillary response.
Apply a cervical collar if the child reports neck pain.
The Correct Answer is C
A. Show the child's parent how to release tension on the bars: The tension on the halo vest is adjusted by the healthcare provider, not by the parent. The nurse should not instruct the parent to release tension, as improper adjustments can lead to complications.
B. Remove the vest for the child to sleep at night: The halo vest should remain in place at all times, including during sleep, to maintain proper cervical traction and stabilization. Removing it may interfere with the healing process and cause further injury.
C. Check the child's pupillary response: Monitoring the pupillary response is important in a child with cervical traction to assess for any neurological changes. It helps identify signs of increased intracranial pressure or other neurological complications.
D. Apply a cervical collar if the child reports neck pain: The halo vest itself is designed to stabilize the neck, and the application of a cervical collar without provider guidance could interfere with the proper use of the traction system.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Gently cleanse the surgical site with sterile gauze: direct vigorous cleansing of the palate surgical site with gauze is generally avoided to prevent disruption of sutures. Oral rinses or specific gentle cleaning methods may be prescribed, but direct gauze wiping is usually not recommended.
B. Offer a pacifier with glucose syrup: acifiers and any sucking on objects (including straws, spoons, or toys) are typically contraindicated after cleft palate repair because the sucking motion puts stress on the suture line and can disrupt healing.
C. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from bending their elbows and bringing their hands to their mouth or face, which could disrupt the surgical sutures, cause trauma, or introduce infection to the delicate palate repair.
D. Place the infant in a supine position: A semi-upright position is usually preferred to reduce pressure on the surgical site and prevent aspiration, rather than placing the infant flat on their back.
Correct Answer is C
Explanation
A. Reinforce with the guardians to avoid discussing death with the child's siblings: Avoiding the discussion of death with the child's siblings can create confusion and anxiety. It's important to foster open communication and allow siblings to process their emotions about the situation in an age-appropriate manner.
B. Guide discussions with the child about death: Discussions about death should be handled delicately, considering the child’s age and understanding; this should be done in partnership with the family and healthcare providers.
C. Use a calm tone of voice when speaking with the child: A calm, reassuring tone of voice is essential when interacting with a child in palliative care. This helps provide comfort, reduces anxiety, and establishes a sense of safety for the child during a difficult time.
D. Encourage the guardians to seek a second opinion about their child's diagnosis:
Seeking a second opinion may be an option in some situations, but in the context of palliative care, the focus is typically on comfort and quality of life rather than pursuing further curative treatments.
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