Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
71. A nursing student is being mentored by a charge nurse on a pediatric unit. The nursing student is assigned to care for a child who has increased intracranial pressure following a head trauma. The charge nurse questions the nursing student regarding positions that would be contraindicated or ineffective when caring for the child. The nursing student should correctly identify:
Select all that apply.
. Prone position.
. Supine position.
. Semi-Fowler's position.
. Right side-lying position.
. Left side-lying position.
Test-Taking Tip
Gravity will assist in the drainage of fluids; select the positions that would prevent or are least likely to accomplish this.
Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Accident Prevention and Injury Prevention
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. In addition, placing the child on the abdomen (prone) could prevent an adequate airway from being maintained. Answer 2 is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. In addition, placing the child on the back (supine) could increase the possibility of aspiration. Answer 3 is incorrect because this position would promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. Semi-Fowler's is a position in which the child lies on the back with the trunk elevated at approximately a 45-degree angle. Answer 4 is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. (However, right side-lying would not prevent an adequate airway from being maintained or increase the possibility of aspiration.) Answer 5 is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. (However, left side-lying would not prevent an adequate airway from being maintained or increase the possibility of aspiration.)