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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This advice may lead to inadequate emptying of the breasts and imbalance in milk production, potentially affecting milk supply and infant feeding.
B. Encouraging feeding on demand promotes effective breastfeeding by allowing the infant to feed when hungry, which helps establish and maintain milk supply. This approach supports infant cues and promotes successful breastfeeding.
C. Strict time limits on feeding can interfere with effective breastfeeding and hinder milk transfer, potentially leading to inadequate nutrition for the infant.
D. Water supplementation is unnecessary for breastfed infants and can interfere with breastfeeding by reducing infant appetite for breast milk.
Correct Answer is C
Explanation
A. This type of play usually begins around ages 3 to 4.
B. While possible, this is more typical in slightly older children who engage in more complex forms of pretend play.
C. At 30 months (2.5 years old), children are typically engaged in simple pretend play and enjoy playing with larger, more manipulable toys like plastic trucks. Their motor skills and cognitive development at this stage support this type of play.
D. Coordination for jumping rope generally develops later, closer to school age.
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