A nurse is caring for a client who is experiencing Increased Intracranial pressure following a head Injury. In which of the following positions should the nurse place the client?

Sims

Supine

Left lateral

Low-Fowler's

Answer and Explanation

The Correct Answer is D

A.   The Sims position is a lateral position used for procedures such as rectal examinations and enemas and is not typically indicated for managing increased intracranial pressure.
B.   The supine position may worsen increased intracranial pressure by increasing venous return and intracranial pressure.
C.   The left lateral position may be used in specific circumstances, such as to relieve pressure on the vena cava in pregnancy, but it is not typically indicated for managing increased intracranial pressure.
D.   Positioning the client in Low-Fowler's position (with the head of the bed elevated approximately 15-30 degrees) helps facilitate venous drainage from the brain, thereby reducing intracranial pressure. This position promotes optimal cerebral perfusion and helps manage increased intracranial pressure.

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Correct Answer is []

Explanation

Condition Most Likely Experiencing:

The client's admission to the behavioral health unit for prolonged weight loss and refusal to eat suggests a significant disordered eating pattern. The client's weight of 37.2 kg (82 lb) and BMI of 15 fall significantly below the healthy range for their height, indicating severe underweight status characteristic of anorexia nervosa. The client's behaviors during meal times, such as pushing food around the plate, eating only a small percentage of meals and snacks, and expressing anxiety about eating in front of others, are consistent with the restrictive eating patterns and fear of weight gain seen in anorexia nervosa.

Physical signs such as dry and flaky skin, dry and chapped lips, thin and dull hair, dry buccal mucosa, diminished bowel sounds, swollen and bloated abdomen, and lanugo (fine, downy hair) are commonly associated with anorexia nervosa due to malnutrition and starvation. The client's reported feelings of depression, initiation of dieting due to feeling fat compared to others, and cessation of menstrual cycles for the past 3 months are all indicative of the psychological and emotional distress often seen in individuals with anorexia nervosa.

Actions to take:

Clients with anorexia nervosa often benefit from a structured meal plan to promote regular eating habits and prevent skipping meals.

Focusing on the client’s underlying feelings of dysphoria and lack of control can help the client develop a more positive self-image and cope with emotional stressors that may trigger their eating disorder.

Parameters to monitor:

Monitoring weight is essential in assessing nutritional status and tracking changes in body composition, especially in clients with anorexia nervosa who may experience rapid weight loss.

Cardiac function with ECG can help the nurse detect any signs of cardiac arrhythmias, bradycardia, hypotension, or electrolyte imbalances that may result from severe malnutrition and dehydration.

A. "I have several friends who come by to help out with the baby." B. "I want to meet other parents to see if they are going through the same things." C. "I think the baby should be sleeping through the night by now." D. "I try to respond to the baby quickly so she doesn't cry very long."

Correct Answer is C

Explanation

A. Having social support from friends is a protective factor against child abuse.

B. Seeking support from other parents indicates a healthy coping mechanism and reduces the risk of child abuse.

C. This statement suggests unrealistic expectations about the baby's development and behavior, which could lead to frustration and increased risk of child abuse. Unrealistic expectations are a risk factor for abusive behavior towards children.
D. This statement reflects attentiveness and responsiveness to the baby's needs, which reduces the risk of child abuse.

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A nurse is caring for a client who is experiencing Increased Intracranial pressure following a head Injury. In which of the following positions should the nurse place the client?

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