A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
Move the client up and down in bed by holding onto the halo traction device.
Ensure that there is space for one finger to fit between the vest and the client's skin.
Apply medicated powder under the vest to reduce itching.
Loosen or tighten the screws on the device as needed for the client's comfort.
The Correct Answer is B
B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.
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Related Questions
Correct Answer is C
Explanation
C. Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
A. While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.
D. While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.
Correct Answer is D
Explanation
D. Hot flashes are a common symptom following a bilateral orchiectomy due to the sudden decrease in testosterone levels. Hot flashes are characterized by sudden feelings of warmth, flushing, and sweating, often accompanied by a rapid heartbeat. These symptoms can be bothersome but are typically temporary and can be managed with lifestyle modifications and medications if necessary.
A. Hypoglycemia is not typically associated with a bilateral orchiectomy.
B. Testosterone, primarily produced by the testicles, plays a significant role in promoting muscle mass and strength. Removal of the testicles results in a significant decrease in testosterone production, which may lead to a gradual decline in muscle mass and strength over time.
C. Testosterone is a key hormone involved in regulating libido in both men and women. Removal of the testicles leads to a significant decrease in testosterone levels, which may result in a decrease in libido rather than an increase.
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