A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?
The client reports relief from pain when lying in the prone position.
The client reports that their low-back pain radiates upward toward one scapula.
The client reports tingling and a burning sensation in one foot.
The client reports decreased pain when the affected leg is raised.
The Correct Answer is C
Choice A Reason
The client reports relief from pain when lying in the prone position. This statement is incorrect. Clients with a herniated lumbar disc typically find relief from pain when lying on their back with their knees bent or in a fetal position. Lying prone can sometimes exacerbate the pain.
Choice B Reason
The client reports that their low-back pain radiates upward toward one scapula. This statement is incorrect. Pain from a herniated lumbar disc usually radiates downward into the buttocks, legs, and sometimes the feet, not upward toward the scapula.
Choice C Reason
The client reports tingling and a burning sensation in one foot. This is the correct finding. A herniated lumbar disc can compress spinal nerves, leading to symptoms such as tingling, numbness, and a burning sensation in the legs and feet.
Choice D Reason
The client reports decreased pain when the affected leg is raised. This statement is incorrect. Raising the affected leg often increases pain due to the stretching of the sciatic nerve, which can be compressed by the herniated disc.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
4g sodium diet. While reducing sodium intake is important for managing chronic kidney disease (CKD), a specific 4g sodium diet is not typically prescribed. Instead, patients are generally advised to limit sodium intake to less than 2,300 milligrams per day to help control blood pressure and reduce fluid retention.
Choice B Reason
Potassium-restricted diet. This is the correct intervention. Patients with CKD often have difficulty excreting potassium, leading to hyperkalemia, which can be dangerous. Therefore, a potassium-restricted diet is commonly recommended to maintain normal serum potassium levels.
Choice C Reason
High-phosphorus diet. This statement is incorrect. Patients with CKD are usually advised to limit phosphorus intake because their kidneys cannot effectively excrete phosphorus, leading to hyperphosphatemia. High phosphorus levels can cause bone and cardiovascular problems.
Choice D Reason
High-protein diet. This statement is incorrect. While protein is essential, excessive protein intake can increase the workload on the kidneys. Patients with CKD are often advised to follow a moderate protein diet to reduce the production of waste products that the kidneys need to filter.
Correct Answer is A
Explanation
Choice A Reason:
A distended, board-like abdomen is a critical finding that can indicate peritonitis, a severe complication of appendicitis. Peritonitis occurs when the appendix ruptures, leading to infection spreading throughout the abdominal cavity. This condition requires immediate medical intervention to prevent further complications and potential sepsis.
Choice B Reason:
A WBC count of 15,000/mm³ is elevated and suggests an infection, which is common in appendicitis. However, it is not as immediately critical as signs of peritonitis. Elevated WBC counts are expected in cases of appendicitis but do not necessarily indicate a life-threatening emergency.
Choice C Reason:
Rebound tenderness over McBurney’s point is a classic sign of appendicitis and indicates localized inflammation. While it is an important diagnostic sign, it does not require immediate reporting compared to signs of peritonitis.
Choice D Reason:
A temperature of 37.3°C (99.1°F) is only slightly elevated and does not indicate a severe infection or complication. Fever is a common symptom of appendicitis but is not as critical as a distended, board-like abdomen.
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