Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
A client with a halo brace 2 days post-spinal cord injury.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?
Correct answer
D
Rationale
The correct answer is D: Assess the pin sites. This is the first priority because monitoring the pin sites for signs of infection or inflammation is crucial to prevent complications such as infection or loosening of the halo brace. This assessment ensures the safety and integrity of the device, which is essential for stabilizing the spine and preventing further damage. Loosening all connections on the vest (choice A) could compromise the brace's effectiveness and stability. Asking about range of motion (choice B) and repositioning in bed (choice C) are important assessments but not as immediate as assessing the pin sites.