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 D

Explanation

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

A. Encourage the client to lie down in a quiet room. B. Avoid eye contact with the client. C. Ask the client directly what he is hearing. D. Refer to the hallucinations as if they are real.

Correct Answer is C

Explanation

A. While rest and a quiet environment can be beneficial, encouraging the client to address the hallucinations directly is more appropriate.
B. Avoiding eye contact may be perceived as dismissive or unhelpful.

C. Engaging the client in open communication about their hallucinations can help build trust and rapport, as well as provide valuable information for treatment planning.
D. Validating hallucinations as real can reinforce delusional thinking and may not be therapeutically beneficial.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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