Question

The nurse is making rounds on a client who is in cervical tongs. Assessment reveals detachment of one of the pins. Which nursing action is most appropriate? A. Call for help immediately and stabilize the clients' head in the neutral position. B. Go to the nursing station and call the neurosurgeon immediately. C. Lower the head of the bed and add more weight to the traction. D. Turn the client to the left side, raising the knee gatch on the bed.

Short answer

Answer: Call for help immediately and stabilize the clients' head in the neutral position.

Step-by-step solution

Analyze Option A

A. Call for help immediately and stabilize the client's head in the neutral position. In this option, the first response is to call for help, which is important in an emergency situation. Additionally, stabilizing the client's head in the neutral position is essential to prevent further injury to the cervical spine.

Analyze Option B

B. Go to the nursing station and call the neurosurgeon immediately. In this option, the focus is on calling the neurosurgeon, which could be helpful, but not immediately addressing the client's safety can lead to further injury.

Analyze Option C

C. Lower the head of the bed and add more weight to the traction. In this option, the focus is on adjusting the bed and the traction, which doesn't directly address the issue of the detached pin or the client's head stability.

Analyze Option D

D. Turn the client to the left side, raising the knee gatch on the bed. In this option, the focus is on turning the client and adjusting the bed, which could further compromise their safety and stability.

Choose the most appropriate action

After analyzing all options, it's clear that Option A is the most appropriate action. It focuses on calling for help and stabilizing the client's head, which are crucial steps in dealing with this emergency situation. Answer: A. Call for help immediately and stabilize the clients' head in the neutral position.

Key concepts

Nursing Assessment

A nursing assessment is a critical step in the patient's care process. This involves gathering comprehensive information about a client’s physiological, psychological, sociological, and spiritual status. The goal is to collect detailed data that will help in diagnosing and creating a tailored care plan.
Nurses must utilize various techniques during an assessment:

• Observation: Noting the client’s behavior, appearance, and reactions.
• Interviewing: Asking the client or significant others about their health history and current status.
• Physical Examination: Using inspection, palpation, percussion, and auscultation to gather data.
  

The case at hand highlights the urgency and importance of nursing assessment. Upon noticing the detached pin in cervical tongs, a nurse must quickly assess the client's condition. This assessment informs the immediate response, ensuring patient safety while minimizing the risk of further injury.

Emergency Nursing Care

Emergency nursing care refers to the rapid assessment and intervention for patients experiencing urgent health crises. The focus is on stabilizing the patient while addressing life-threatening conditions. Nurses in emergency situations must possess quick decision-making skills and the ability to perform under pressure.
In emergency situations like a detached pin from cervical tongs, the correct response prioritizes safety. Swift identification of issues, like potential spinal instability, is crucial. Immediate steps should include:

• Calling for additional help to manage the situation efficiently.
• Stabilizing the client's position to prevent further injury until medical intervention is realized.
• Ensuring the patient remains calm and comfortable during the emergency response.
  

Effective emergency nursing care involves fast, accurate assessments followed by informed actions, guided by clinical protocols and the nurse’s expertise. This approach ensures patients receive timely, appropriate care, potentially preventing further complications.

Cervical Spine Stabilization

Cervical spine stabilization is vital in preventing further damage following a suspected or confirmed injury to the neck area. The cervical spine is delicate and supports the head's weight, also protecting the spinal cord that runs through it. Issues in stabilizing this area can lead to severe injuries or worsen existing ones.
In cases where a pin from cervical tongs detaches, stabilization becomes a priority. Such situations call for immediate action:

• The head should be maintained in a neutral position. This position helps avoid undue pressure on the neck and spinal cord.
• Properly sizing and applying a cervical collar complements manual stabilization, providing further support.
• Continuous monitoring of the client's neurological status ensures any changes are immediately addressed.
  

Successful cervical spine stabilization protects the spinal cord from additional injury. These efforts are particularly crucial in emergency nursing care settings, where timely intervention can impact overall recovery positively.