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.
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Related Questions
Correct Answer is B
Explanation
A. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
B. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerging the feet in ice water is not recommended as it can cause vasoconstriction and shivering, which may increase the body temperature. Instead, tepid sponging and providing a cool environment can be beneficial.
D. Covering the adolescent with a thermal blanket would retain body heat and exacerbate hyperthermia, counteracting efforts to lower the body temperature.
Correct Answer is C
Explanation
A: Directing anyone who becomes angry to leave the room may escalate tensions and hinder resolution.
B: Establishing demands from each party can create a confrontational atmosphere where parties are more focused on winning than resolving the conflict.
C: In resolving staff conflicts, facilitating discussion until all parties agree is a constructive strategy that promotes understanding and collaboration. This approach encourages open communication, allows for the expression of different viewpoints, and works towards a consensus that respects everyone's needs and concerns.
D: Determining fault can increase defensiveness and hinder collaboration in resolving the conflict. It is counterproductive as it places blame, which can lead to defensiveness and hinder the resolution process.
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