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Difficulty: HardBasic Care and Comfort

During interdisciplinary rounds, the nursing team discusses interventions for a client newly fitted with a halo vest apparatus for a stable cervical fracture. Which specific actions should be incorporated into the client's daily regimen? Select all that apply.

  1. Clean the skin underneath the vest using a clean, damp cloth without soap or lotion.Answer
  2. B
    Turn and reposition the client every two hours by grasping the device's vertical struts.
  3. Serve meals with solid foods cut into small, bite-sized pieces and provide a long straw.Answer
  4. D
    Assign the unlicensed assistive personnel (UAP) to evaluate the pin sites for signs of infection.
  5. E
    Implement bilateral soft wrist restraints at night to prevent the client from pulling the fixation pins.
  6. Place a small, flat pillow under the client's head to decrease pressure when resting supine.Answer

Answer

The correct actions include cleaning the skin under the vest with a damp cloth, cutting food into bite-sized pieces with a straw provided, and placing a small pillow under the head when supine.
The correct interventions address the unique hygiene, nutritional, and comfort needs of a client with a cervical immobilization device. Cleaning the skin with a damp cloth prevents chemical irritation from soaps and lotions building up underneath the vest. Serving pre-cut food and providing a straw compensates for the client's inability to flex their neck, reducing the risk of aspiration and promoting adequate intake. Placing a small, flat pillow under the head when supine prevents the posterior vest from pushing the head forward, ensuring comfort and neutral alignment.

Step-by-Step Solution

1
Analyze the client's condition and the physiological constraints of a halo fixator device.
The device immobilizes the cervical spine, alters the client's center of gravity, restricts neck flexion, and permanently covers the torso.
Understanding the physical limitations imposed by the device dictates the necessary modifications for basic care, hygiene, and nutrition.
2
Evaluate the proposed hygiene and nutritional interventions.
Using only a damp cloth under the vest prevents skin breakdown from chemical buildup. Pre-cut food and long straws accommodate the client's inability to look down while eating.
Basic care must adapt to the physical limitations and maintain tissue integrity without compromising safety.
3
Review the options involving positioning, delegation, and safety restraints.
A small pillow safely supports the head. However, pulling on struts compromises the device's stability, assessing pin sites is strictly an RN responsibility, and routine restraints violate standard safety protocols.
Nurses must differentiate between standard supportive care and contraindicated actions that jeopardize the client or violate the scope of practice.

Key Concept

Nursing Management of Halo Fixation Devices
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Topics

Basic Care and Comfort

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