The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?
Loosen all of the connections on the vest to assess the skin
Ask about the client's ability to perform range of motion to legs
Ask how the client is able to reposition self in bed
Assess the pin sites
The Correct Answer is D
Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.
Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.
Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.
Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Draining the bladder with a clean intermittent catheter at appropriate intervals is an essential part of managing urinary system complications in clients with spinal cord injury to prevent urinary retention and complications.
Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important for overall health.
Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.
Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications. Clean intermittent catheterization is often preferred.
Correct Answer is D
Explanation
Choice A Rationale: Linking the pain to nasal stuffiness is not an accurate explanation of trigeminal neuralgia.
Choice B Rationale: Hypoglycemia is not typically related to trigeminal neuralgia.
Choice C Rationale: Releasing catecholamines with infection or stress is not the primary cause of trigeminal neuralgia.
Choice D Rationale: Pain is often due to stimulation of the affected nerve by pressure and temperature. This is a more accurate and relevant explanation for trigeminal neuralgia.
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