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 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. .

A. “Does drinking coffee or ingesting chocolate seem related to the episodes?” B. “Does being exposed to heat seem to cause the episodes?” C. “Do the signs and symptoms occur while you are asleep?” D. “Have you experienced any injuries that have limited your activity levels lately?”

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.

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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 caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

Correct Answer is D

Explanation

A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?

Correct Answer is A

Explanation

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