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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.

Choice B rationale

Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.

Choice C rationale

Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.

Choice D rationale

Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.

A. “Soon those shock waves will get rid of my gallstones.”. B. “I’ll have a camera put down my throat so they can see my gallbladder.”. C. “They are going to use dye to examine my gallbladder and ducts.”. D. “They’ll put medication into my gallbladder to dissolve the stones.”.

Correct Answer is C

Explanation

Choice A rationale

Lithotripsy, which uses shock waves to break up stones, is not part of an oral cholangiogram. An oral cholangiogram involves the use of a contrast dye to visualize the gallbladder and bile ducts on X-ray.

Choice B rationale

An endoscopic procedure, such as an endoscopic retrograde cholangiopancreatography (ERCP), involves inserting a camera down the throat. However, an oral cholangiogram is a non- invasive imaging test that uses contrast dye.

Choice C rationale

Correct. An oral cholangiogram involves the ingestion of a contrast dye that helps visualize the gallbladder and bile ducts on X-ray.

Choice D rationale

Medications to dissolve gallstones are not used in an oral cholangiogram. This procedure is purely diagnostic and involves the use of contrast dye to visualize the gallbladder and bile ducts.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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