The nurse should elevate the client's head to 90 degrees.
Other given options may induce the heart attack and can be proven as harmful for the health of the client. The hepato-jugular reflex is a reliable physical sign for the treatment and diagnosis of congestive heart failure. It occurs earlier than other conventional signs and symptoms of heart failure.
1. elevate the client's head to 90 degrees.- rationale: as the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle. The client needs category: physiological integrity, the client needs subcategory: reduction of risk potential, cognitive level: application
reference: Smeltzer, s.c., et al. Brunner & Suddarth's textbook of medical surgical-nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 805.