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. Chronic kidney disease often results in metabolic acidosis, leading to decreased bicarbonate levels rather than increased.
B. Chronic kidney disease commonly leads to hyperphosphatemia and hypocalcemia due to impaired renal excretion of phosphate and decreased activation of vitamin D, resulting in decreased calcium levels.
C. Chronic kidney disease often results in anemia due to decreased production of erythropoietin, leading to decreased hemoglobin levels rather than increased.
D. Increased creatinine levels are indicative of impaired renal function, a hallmark of chronic kidney disease.

A. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." B. "I should visually monitor the client continuously when in mechanical restraints." C. "I should ask the provider to write a prescription for mechanical restraints as needed." D. "I should expect the provider to evaluate the client within 4 hours of restraint application."

Correct Answer is B

Explanation

A. Skin integrity should be assessed more frequently, generally every 2 hours.

B. Continuous visual monitoring is required to ensure the safety and well-being of a client who is in mechanical restraints, to respond promptly to any distress or complications.
C. Restraints should be a last resort and not prescribed as needed.

D. The provider should evaluate the client sooner, typically within 1 hour of applying restraints.

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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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Correct Answer is B

Explanation

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