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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
Correct Answer is C
Explanation
A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.
B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.
C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.
D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.
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