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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Laterally on the left side with a pillow under the head and the right arm and hand hyperextended

Supine with a pillow under the head, and elevate the right hand and arm on a pillow

Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillow

Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Answer and Explanation

The Correct Answer is C

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

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Correct Answer is B

Explanation

A. Removal of the educating patient to carry an Epipen
While educating the patient about carrying an Epipen is essential in managing anaphylaxis, it is not the primary action in preventing anaphylactic shock before exposure to an allergen.

B. Assess and document for previous allergies and drug reactions prior to medication administration
Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.

C. Administer diphenhydramine and solumedrol IV at the first sign of allergic symptoms
These medications help in managing allergic reactions but do not prevent anaphylactic shock. Preventive measures focus on avoiding allergen exposure rather than treating symptoms after they occur.

D. Application of a red allergy bracelet on the patient’s upper extremity
This helps alert healthcare providers about allergies, but it does not prevent anaphylactic shock. It is a precautionary step rather than a primary prevention strategy.

A. Reassure the client that information they share with the nurse is confidential B. Instruct that complementary therapies are rarely helpful C. Assess physical appearance and gait D. Review current medication list including dosage & frequency E. Ask about current alcohol or drug use

Correct Answer is ["A","C","D","E"]

Explanation

A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.

B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.

C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.

D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.

E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.

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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What action priority in preventing anaphylactic shock?

Correct Answer is B

Explanation

A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

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