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 B
Explanation
A. Insufficient insulin production is related to diabetes mellitus, not Cushing's syndrome.
B. Long-term use of glucocorticoids is a well-known exogenous cause of Cushing's syndrome, as it leads to excess cortisol in the body.
C. Adrenal insufficiency refers to a deficiency of adrenal hormones and would not cause Cushing's syndrome, which is characterized by excess hormones.
D. Overproduction of growth hormones is associated with acromegaly or gigantism, not Cushing's syndrome, which primarily involves excess cortisol.
Correct Answer is C
Explanation
A. While pain level assessment is important, it is not the priority immediately after a significant brain injury where neurological changes may occur.
B. Wound site assessment is also essential but does not take precedence over neurological assessment in this context.
C. A neurological assessment is the priority to identify any changes in the client's condition that may indicate complications such as increased intracranial pressure, which can occur after brain surgery.
D. Respiratory status assessment is important but is usually addressed through monitoring and interventions related to neurological function, as brain injuries can affect respiratory drive and function.