The nurse assesses a client in the burn unit after the client was repositioned by the nursing assistant. The nurse intervenes after finding the client repositioned in what manner?
a. Supine with one pillow behind the head
b. Semi-Fowler's position with arms elevated
c. Wrists extended to 30 degrees in a splint
d. A towel roll placed under the neck or shoulder
A
Clients must be positioned to prevent contractures. The function that would be disrupted by a contracture to the posterior neck is flexion. The client should not be positioned with a pillow be-hind the head; this would increase flexion. The nurse must intervene and position the client so that neck flexion does not occur. The other options include proper positioning techniques that will help prevent contracture.
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