A nurse is providing care for a client with a halo device. The client has developed skin breakdown and irritation around the pin sites. Which intervention is most appropriate for the nurse to implement to prevent further skin complications?
Ensure that the vest supporting the halo device is snug and properly aligned.
Apply a thick layer of zinc oxide cream around the pin sites.
Pad the areas of skin breakdown with foam dressing to reduce friction and pressure.
Loosen the halo device to reduce pressure on the skin.
The Correct Answer is C
A. While ensuring proper alignment is important, it does not address the existing skin breakdown and irritation.
B. Applying zinc oxide cream may not be appropriate as it can trap moisture, potentially worsening the skin condition around pin sites.
C. Padding the areas of skin breakdown with foam dressing is an appropriate intervention as it can provide cushioning, reduce friction, and protect the skin from further injury.
D. Loosening the halo device could compromise the stabilization it provides and may not effectively address skin integrity issues.
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Correct Answer is ["A","C","D"]
Explanation
A. Calcium binders are used to help decrease the amount of calcium absorbed from the gastrointestinal tract, thus lowering calcium levels in the blood.
B. Vitamin D supplements would actually increase calcium levels by enhancing intestinal absorption, so this option is not appropriate in hypercalcemia.
C. Administering fluids helps to dilute serum calcium levels and promote renal excretion of calcium, making it a priority treatment.
D. Furosemide (Lasix) can help promote diuresis, thereby increasing the excretion of calcium through the urine, which is beneficial in managing hypercalcemia.
E. Oral phosphates may be used in some cases to manage hypercalcemia, but they are not a first-line treatment and their administration should be carefully considered in conjunction with other treatments.
Correct Answer is C
Explanation
A. Bradycardia is not a common finding in diabetes insipidus; rather, patients may experience tachycardia due to volume depletion.
B. Bounding peripheral pulses may occur in conditions with fluid overload, which is not typical in diabetes insipidus where there is a lack of fluid retention.
C. Urine specific gravity of 1.002 indicates dilute urine, which is consistent with diabetes insipidus, where the body fails to concentrate urine due to insufficient antidiuretic hormone (ADH).
D. Clients with diabetes insipidus typically experience polyuria, resulting in increased urine output rather than normal levels