A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Remove the vest daily to inspect the client’s skin integrity.
Check that the halo jacket is snug against the client’s skin.
Provide range of motion to the client’s neck.
Monitor the client for an elevated temperature.
The Correct Answer is D
Choice A rationale
Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.
Choice B rationale
The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.
Choice C rationale
Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.
Choice D rationale
Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
According to the Rule of Nines, the percentage of body surface area for different parts of the body is calculated to estimate burn severity. For example, the anterior and posterior aspects of each leg account for 18% each, and the back accounts for 18%. Therefore, the total body surface area burned can be estimated based on these percentages.
Correct Answer is A
Explanation
Choice A rationale
Silvery, white scales are a characteristic finding in psoriasis. Psoriasis is a chronic autoimmune condition that causes rapid skin cell turnover, leading to the buildup of scales and red patches on the skin.
Choice B rationale
Intense pain is not typically associated with psoriasis. While psoriasis can cause discomfort and itching, it is not usually described as intensely painful.
Choice C rationale
Unilateral lesions are not characteristic of psoriasis. Psoriasis typically presents with symmetrical lesions on both sides of the body.
Choice D rationale
Serous drainage is not a common finding in psoriasis. Psoriasis lesions are usually dry and scaly rather than exudative. .
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.