A client is admitted to your inpatient rehabilitation unit. This client is currently in halo traction. (See exhibit.)Based on this information, which of the following should be the priority nursing diagnosis for the client?
A)Risk for Peripheral Neurovascular Dysfunction related to disruption of traction weights
B)Risk for Infection related to surgical incision and insertion of hardware
C)Risk for Disuse Syndrome related to use of traction to stabilize fracture
D)Acute Pain related to bone and soft tissue damage

Question

A client is admitted to your inpatient rehabilitation unit. This client is currently in halo traction. (See exhibit.)Based on this information, which of the following should be the priority nursing diagnosis for the client? 
A)Risk for Peripheral Neurovascular Dysfunction related to disruption of traction weights 
B)Risk for Infection related to surgical incision and insertion of hardware 
C)Risk for Disuse Syndrome related to use of traction to stabilize fracture 
D)Acute Pain related to bone and soft tissue damage

Quizplus · Accepted Answer

A)Halo traction uses pins that are surgically implanted in the skull, which increases the risk for infection. Acute pain is not as high a priority as the risk for infection. Risk for Disuse is another appropriate but lower-priority diagnosis. Halo traction is not connected to weights, so this particular diagnosis of Risk for Peripheral Neurovascular Dysfunction is not applicable.
B)Halo traction uses pins that are surgically implanted in the skull, which increases the risk for infection. Acute pain is not as high a priority as the risk for infection. Risk for Disuse is another appropriate but lower-priority diagnosis. Halo traction is not connected to weights, so this particular diagnosis of Risk for Peripheral Neurovascular Dysfunction is not applicable.
C)Halo traction uses pins that are surgically implanted in the skull, which increases the risk for infection. Acute pain is not as high a priority as the risk for infection. Risk for Disuse is another appropriate but lower-priority diagnosis. Halo traction is not connected to weights, so this particular diagnosis of Risk for Peripheral Neurovascular Dysfunction is not applicable.
D)Halo traction uses pins that are surgically implanted in the skull, which increases the risk for infection. Acute pain is not as high a priority as the risk for infection. Risk for Disuse is another appropriate but lower-priority diagnosis. Halo traction is not connected to weights, so this particular diagnosis of Risk for Peripheral Neurovascular Dysfunction is not applicable.

A Client Is Admitted to Your Inpatient Rehabilitation Unit