A nurse is contributing to the plan of care for a client who has a halo vest after experiencing a cervical fracture 8 hr ago. Which of the following interventions should the nurse recommend including in the plan?
Reposition the client in bed using the halo ring.
Turn the client every 4 hr.
Loosen the screws while cleansing the pin sites.
Change the sheepskin lining under the device weekly.
The Correct Answer is A
A. When caring for a client with a halo vest after a cervical fracture, it's essential to maintain spinal alignment and prevent further injury. Repositioning the client using the halo ring ensures that the cervical spine remains immobilized during movement, thereby reducing the risk of additional damage. This method provides controlled movement while preserving the integrity of the spinal column.
B. This is incorrect. While frequent turning is necessary to prevent complications such as pressure injuries, turning every 2 hours (not 4) is the standard for immobile clients.
C. Loosen the screws while cleansing the pin sites: This is incorrect as loosening the screws can compromise the stability of the halo vest. Pin site care should be done carefully without altering the tension of the screws.
D. Change the sheepskin lining under the device weekly: This is not frequent enough for proper hygiene and skin care; the lining should be checked more regularly and changed as needed to maintain skin integrity and comfort.
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Related Questions
Correct Answer is B
Explanation
A. Speech therapist: A speech therapist is typically involved in addressing communication and swallowing difficulties, not difficulties with using utensils.
B. Occupational therapist: This is correct as an occupational therapist specializes in helping clients with daily living activities, including fine motor skills and adaptive techniques for using utensils.
C. Physical therapist: Physical therapists focus on improving mobility, strength, and coordination but do not primarily address difficulties with using utensils.
D. Recreational therapist: Recreational therapists focus on leisure activities and hobbies, which are not directly related to the use of utensils for eating.
Correct Answer is D
Explanation
A. Store the medication in the refrigerator: Diltiazem sustained-release tablets do not need to be refrigerated; they should be stored at room temperature, away from moisture and heat.
B. Take the medication at mealtime: It is not necessary to take diltiazem with food unless specifically advised by a healthcare provider. Generally, it can be taken with or without food.
C. Drink grapefruit juice with the medication: Grapefruit juice should be avoided with diltiazem as it can increase the risk of adverse effects by altering the metabolism of the drug.
D. Swallow the medication whole: This is correct as sustained-release tablets should not be chewed or crushed. They are designed to release the medication slowly over time, which can be disrupted if the tablet is altered.
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