What Interventions Will the Nurse Include in the Plan of Care

What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A) Assess motor and sensory function every shift.
B) Have the patient hold onto the halo struts during turns and repositioning.
C) Keep the pins and traction bars slightly loose to prevent pressure ulcers.
D) Tape a halo vest wrench to the front of the vest.
E) Use a moist cloth to clean the skin under the vest.