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
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B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.
Correct Answer is A
Explanation
A. Baked fish is rich in iodine, which supports thyroid function and can be beneficial for clients with hypothyroidism. Iodine is necessary for thyroid hormone production.
B. Tuna salad may contain iodine, but it is not as reliable a source as baked fish and may also contain added fats.
C. Bran flakes are high in fiber, which can interfere with the absorption of thyroid medications.
D. Cantaloupe, while nutritious, does not provide significant levels of iodine or nutrients that directly support thyroid function.