A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client?

Sims

Modified Trendelenburg

Semi-Fowler's

Prone

Answer and Explanation

The Correct Answer is C

Choice A: This is incorrect because Sims position is used for clients who have lower back pain, abdominal surgery, or enemas. It is not appropriate for clients who have a closed head injury.

Choice B: This is incorrect because modified Trendelenburg position is used for clients who have hypovolemic shock or poor venous return. It is not appropriate for clients who have a closed head injury.

Choice C: This is correct because semi-Fowler's position is used for clients who have increased intracranial pressure, respiratory distress, or head trauma. It elevates the head and chest to reduce cerebral edema and facilitate breathing.

Choice D: This is incorrect because prone position is used for clients who have acute respiratory distress syndrome, spinal cord injury, or pressure ulcers. It is not appropriate for clients who have a closed head injury.

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Correct Answer is D

Explanation

Choice A reason: Ammonia 55 mg/dL is within the normal range of 15 to 60 mg/dL and does not indicate any liver dysfunction or bleeding risk.

Choice B reason: Bilirubin 1.0 mg/dL is within the normal range of 0.3 to 1.2 mg/dL and does not indicate any liver damage or jaundice.

Choice C reason: Aspartate aminotransferase 34 units/L is within the normal range of 10 to 40 units/L and does not indicate any liver inflammation or injury.

Choice D reason: Platelets 60,000/mm³ is below the normal range of 150,000 to 450,000/mm³ and indicates thrombocytopenia, which is a low platelet count that can increase the risk of bleeding during or after the liver biopsy. The nurse should report this value to the provider and monitor the client for signs of bleeding, such as bruising, petechiae, hematuria, or melena.

A. Hyperactive deep tendon reflexes B. Hypoactive bowel sounds C. Positive Chvostek's sign D. Lethargy

Correct Answer is C

Explanation

Choice A: This is incorrect because hyperactive deep tendon reflexes are not associated with low serum calcium levels. Hyperactive deep tendon reflexes can indicate hypomagnesemia, hyperthyroidism, or spinal cord injury.

Choice B: This is incorrect because hypoactive bowel sounds are not associated with low serum calcium levels. Hypoactive bowel sounds can indicate ileus, peritonitis, or opioid use.

Choice C: This is correct because positive Chvostek's sign is associated with low serum calcium levels. Positive Chvostek's sign is a facial muscle spasm that occurs when tapping on the cheek near the ear. It indicates hypocalcemia, which can be caused by hemodialysis, renal failure, or parathyroid dysfunction.

Choice D: This is incorrect because lethargy is not associated with low serum calcium levels. Lethargy can indicate hypercalcemia, dehydration, hypoglycemia, or infection.

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A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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