A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
A The purpose of this device is to immobilize the cervical spine."
B The purpose of this device is to allow for neck movement during the healing process."
C "Apply talcum powder under the vest to limit friction."
D Tum the screws on the device once each day."
The Correct Answer is A
Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.
Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.
Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.
Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Stage 3 of Alzheimer's disease is characterized by increased memory deficits, but the behavior of filling in information with made-up stories is more commonly associated with the earlier stages.
Choice B Rationale: Stage 2 of Alzheimer's disease involves progressive cognitive decline but may not necessarily manifest with the specific behavior described.
Choice C Rationale: Stage 1 of Alzheimer's disease typically has mild cognitive changes, but the behavior mentioned is more indicative of the later stages.
Choice D Rationale: The early stage of Alzheimer's disease may involve the emergence of confabulation, where clients fill in gaps in memory with fabricated stories or information.
Correct Answer is D
Explanation
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
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