A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
Position the client flat as directed.
Leave the client to rest and do not perform any assessments.
Provide caffeine-rich drinks to the client.
Avoid administering analgesic agents to the client.
Avoid administering analgesic agents to the client.
The Correct Answer is A
Choice A rationale
Positioning the client flat as directed is the priority intervention after a lumbar puncture to prevent cerebrospinal fluid (CSF) leakage, which can lead to a post-lumbar puncture headache. This position helps maintain normal CSF pressure and promotes sealing of the puncture site.
Choice B rationale
Leaving the client to rest without performing any assessments is not appropriate, as continuous monitoring is necessary to detect any complications such as bleeding or changes in neurological status. Regular assessments help ensure timely intervention if issues arise.
Choice C rationale
Providing caffeine-rich drinks is sometimes recommended to alleviate headaches caused by CSF leakage post-lumbar puncture. However, it is not the priority intervention immediately after the procedure, which focuses on positioning and monitoring.
Choice D rationale
Avoiding analgesic agents is incorrect. Pain management is an important aspect of care post-lumbar puncture, and appropriate analgesics should be administered as needed. The focus should be on positioning and monitoring, not withholding pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The dura mater is the outermost, tough, and fibrous layer of the meninges that provides protection to the brain and spinal cord.
Choice B rationale
Meninges collectively refer to the three layers of protective membranes (dura mater, arachnoid mater, and pia mater) that cover the brain and spinal cord.
Choice C rationale
The pia mater is the delicate innermost layer of the meninges that closely envelopes the brain and spinal cord, providing support and nourishment.
Choice D rationale
The arachnoid mater is the middle layer of the meninges that has a web-like appearance and provides cushioning for the brain and spinal cord.
Correct Answer is B
Explanation
Choice A rationale
Scoliosis refers to a lateral curvature of the spine, not an exaggeration of the lumbar spine curve, which is characterized by lordosis.
Choice B rationale
Lordosis is an exaggerated inward curve of the lumbar spine, often referred to as swayback. This condition is identified by the nurse as the client presents with an exaggerated lumbar curve.
Choice C rationale
Kyphosis describes an excessive outward curvature of the thoracic spine, resulting in a hunched back, not the lumbar spine.
Choice D rationale
Dowager's hump is a term commonly associated with kyphosis, characterized by a pronounced curvature of the upper back, not the lumbar region.
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