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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Related Questions
Complete the following sentence by using the lists of options.
The nurse should recommend to
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
- Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
- Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
- Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
- Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.
Correct Answer is B
Explanation
A. Explain the risks associated with the procedure: Explaining risks is important, but it's the provider's responsibility to provide detailed information about risks, benefits, and alternatives. The nurse should ensure understanding.
B. Determine the parent's understanding of the procedure: The nurse's role is to ensure the parent understands the procedure. This includes confirming comprehension and providing clarification if needed.
C. Provide detailed information about the procedure to the parent: The nurse may provide general information, but the detailed explanation of the procedure, risks, and benefits should come from the provider.
D. Discuss the benefits of the procedure: Discussing benefits is part of informed consent, but it should be explained by the provider. The nurse’s role is ensuring understanding, not providing detailed explanations.