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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Avoid using an electric razor
This is not directly relevant to trigeminal neuralgia management. Although it may be important for clients to avoid stimulating the face in general, an electric razor is not a specific concern for trigeminal neuralgia.

B. Meats should be served hot
Hot foods should actually be avoided, as extreme temperatures can trigger trigeminal neuralgia pain. Therefore, this recommendation is incorrect.

C. Teeth should be brushed prior to each meal
This is a reasonable recommendation for maintaining oral hygiene, but it does not specifically address managing trigeminal neuralgia pain. It is not as effective as the correct measure for managing trigeminal neuralgia.

D. Chew food on the unaffected side
Clients with trigeminal neuralgia may experience severe pain on one side of the face, especially when chewing. To reduce pain, it is recommended to chew food on the unaffected side to avoid triggering pain.

A. Vocalization, strength, and pupillary response and accommodation B. Eye opening. verbal response, and motor response C. Pupillary reaction, eye opening, and motor response D. Motor response. sensory response, and level of consciousness

Correct Answer is B

Explanation

A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.

B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.

C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.

D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.

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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following measures would the nurse emphasize to assist the client diagnosed with trigeminal neuralgia in managing their pain?

Correct Answer is D

Explanation

What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

Correct Answer is B

Explanation

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