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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.
Correct Answer is D
Explanation
A. Elevate legs on pillows when in bed: This is incorrect because elevating the legs can reduce blood flow in peripheral arterial disease, and it is generally advised to keep the legs at the level of the heart or lower to promote better circulation.
B. Apply heating pad for 15 min twice per day: This is incorrect because applying heat directly to the legs is not recommended as it can lead to burns or other complications, especially in patients with peripheral vascular issues.
C. Wear knee-high support hose during the day: This is incorrect because support hose can sometimes exacerbate symptoms of peripheral arterial disease by restricting blood flow. Compression stockings are generally not recommended.
D. Begin an exercise program that includes walking: This is correct because walking and other forms of exercise improve circulation and help alleviate symptoms of peripheral arterial disease by promoting better blood flow and cardiovascular health.
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