A nurse is caring for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Monitor the client for an elevated temperature.
Ensure the halo jacket is snug against the client's skin.
Provide range of motion to the client's neck
Remove the vest daily to inspect the client's skin integrity.
The Correct Answer is A
Choice A Reason:
Monitoring the client for an elevated temperature is crucial because it can indicate an infection at the pin sites or other complications. Infections are a common risk with halo fixation devices due to the invasive nature of the pins.
Choice B Reason:
Ensuring the halo jacket is snug against the client's skin is incorrect. The halo jacket should fit properly but not be too tight, as this can cause skin breakdown and discomfort. There should be enough space to insert a flat hand between the vest and the skin.
Choice C Reason:
Providing range of motion to the client's neck is not appropriate for a client with a halo fixation device. The purpose of the halo is to immobilize the neck to allow for proper healing of cervical injuries. Any movement could jeopardize the stability of the injury.
Choice D Reason:
Removing the vest daily to inspect the client's skin integrity is incorrect. The halo vest should not be removed frequently as it is meant to provide continuous immobilization. Skin integrity can be monitored by checking the areas around the vest without removing it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Consuming a diet high in vitamin K to promote clotting is not typically recommended for patients with DIC. While vitamin K is essential for clotting, DIC involves both excessive clotting and bleeding. Increasing vitamin K intake could exacerbate clotting issues without addressing the underlying imbalance.
Choice B Reason:
Stopping all medications to prevent interactions with clotting factors is not advisable. Patients with DIC often require medications to manage their condition, including anticoagulants and treatments for the underlying cause. Discontinuing all medications could lead to uncontrolled symptoms and complications.
Choice C Reason:
Engaging in physical activity to promote blood flow is generally beneficial for overall health, but in the context of DIC, it must be approached with caution. Physical activity can increase the risk of injury and bleeding, which is a significant concern for patients with DIC. Therefore, any exercise regimen should be carefully monitored and tailored to the patient's condition.
Choice D Reason:
Avoiding activities that may cause injury or bleeding is crucial for patients with DIC. Due to the risk of spontaneous bleeding and the potential for minor injuries to lead to significant blood loss, patients must take precautions to minimize these risks. This includes avoiding contact sports, using soft-bristled toothbrushes, and being cautious with sharp objects.
Correct Answer is C
Explanation
Choice A Reason:
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typically 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.
Choice B Reason:
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.
Choice C Reason:
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.
Choice D Reason:
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today