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 B

Explanation

A: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.

A. Document the reaction in the medical record. B. Administer epinephrine subcutaneously. C. Infuse 500 mL lactated Ringer's IV. D. Place the blood bag in a biohazard bag before discarding.

Correct Answer is A

Explanation

A. Documenting the transfusion reaction in the medical record is essential for accurate documentation and communication among the healthcare team.
B. Administering epinephrine subcutaneously is not indicated for febrile transfusion reactions. It is instead indicated for anaphylaxis.
C. Infusing lactated Ringer's IV may be indicated for managing transfusion reactions, but the specific treatment depends on the type and severity of the reaction. It's essential to consult with the healthcare provider for appropriate interventions.
D. Placing the blood bag in a biohazard bag before discarding is a routine procedure for disposing of blood products but is not the immediate priority when managing a transfusion reaction.

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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 B

Explanation

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Correct Answer is A

Explanation

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