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 B
Explanation
Choice A rationale
Avoid handwashing after eating. This statement is incorrect. Handwashing is a critical preventive measure to reduce the risk of viral hepatitis, especially after eating or using the restroom.
Choice B rationale
Avoid foods prepared with tap water. This statement is correct. In areas where the water supply may be contaminated, it is essential to avoid foods prepared with tap water to reduce the risk of viral hepatitis, particularly hepatitis A, which can be transmitted through contaminated food and water.
Choice C rationale
Avoid eating meat. This statement is incorrect. While it is essential to ensure that meat is cooked thoroughly to prevent foodborne illnesses, avoiding meat altogether is not a specific preventive measure for viral hepatitis.
Choice D rationale
Avoid covering sores with bandages. This statement is incorrect. Covering sores with bandages can help prevent the spread of infections, including viral hepatitis, by reducing the risk of contact with infectious fluids.
Correct Answer is ["A","B","D","E","F"]
Explanation
Choice A rationale
Prealbumin level is an important indicator of nutritional status. Low prealbumin levels can indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for tissue repair and regeneration.
Choice B rationale
History of diabetes mellitus is a significant factor that can delay wound healing. Diabetes can impair blood flow and reduce the supply of oxygen and nutrients to the wound, leading to slower healing.
Choice C rationale
History of hyperlipidemia is not directly associated with delayed wound healing. While it can contribute to other health issues, it is not a primary factor in wound healing.
Choice D rationale
Wound infection is a major factor that can delay wound healing. Infections can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.
Choice E rationale
Decreased pedal perfusion indicates poor blood flow to the lower extremities. Adequate blood flow is crucial for delivering oxygen and nutrients to the wound site, and decreased perfusion can significantly delay healing.
Choice F rationale
Fasting blood glucose levels are important in managing diabetes. High blood glucose levels can impair the immune response and reduce the body’s ability to heal wounds effectively.
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