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
Choice A rationale
Irregular pulse. While an irregular pulse is a common finding in atrial fibrillation, it is not the most critical finding to report immediately unless it is associated with other symptoms.
Choice B rationale
Persistent fatigue. Persistent fatigue is a common symptom in heart failure and atrial fibrillation but does not require immediate reporting unless it worsens significantly.
Choice C rationale
Dependent edema. Dependent edema is a common symptom in heart failure but does not require immediate reporting unless it is severe or worsening rapidly.
Choice D rationale
Slurred speech. This finding is critical to report immediately as it may indicate a stroke or transient ischemic attack (TIA) due to an embolus from atrial fibrillation. Prompt intervention is necessary to prevent further complications. .
Correct Answer is A
Explanation
Choice A rationale
Drinking coffee or ingesting chocolate can trigger Raynaud’s disease symptoms. Both caffeine and chocolate can cause vasoconstriction, which can exacerbate the symptoms of Raynaud’s disease.
Choice B rationale
Being exposed to heat is not a common trigger for Raynaud’s disease. The condition is typically triggered by cold temperatures or stress.
Choice C rationale
Symptoms of Raynaud’s disease do not typically occur while asleep. The condition is more likely to be triggered by cold or stress during waking hours.
Choice D rationale
Injuries that limit activity levels are not directly related to the triggers of Raynaud’s disease. The primary triggers are cold temperatures and stress.
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.