A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
Encourage flexion and extension of the neck.
Reposition the client using a turning sheet.
Assess the pin sites for infection once every other day.
Tighten the screws on the halo device one-quarter turn every 48 hr.
The Correct Answer is B
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
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Related Questions
Correct Answer is C
Explanation
A. Holding urine for extended periods may indicate urinary retention, which is not the desired outcome of treatment for enuresis.
B. Drinking less may not necessarily indicate treatment effectiveness and could lead to dehydration.
C. Waking to urinate in response to the alarm indicates improved bladder control and responsiveness to conditioning therapy for enuresis.
D. Kegel exercises primarily target pelvic floor muscles and may not directly address the underlying causes of enuresis.
Correct Answer is B
Explanation
D. Renal failure Correct Answer: B Rationale:
A. Stevens-Johnson syndrome is a severe allergic reaction that can occur with various medications, but it is not a common adverse effect of prednisolone.
B. Prolonged wound healing is a potential adverse effect of corticosteroids like prednisolone due to their immunosuppressive effects.
C. Hypotension is not a common adverse effect of prednisolone; rather, it can cause fluid retention and hypertension.
D. Renal failure is a rare adverse effect of prednisolone and is not typically monitored for in school-age children unless there are preexisting renal issues.
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