A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis.
Into which of the following positions should the nurse assist the client?
Arms raised above her head with her legs elevated on pillows.
Trendelenburg with her body in Sims' position.
Prone with her arms at her side and her legs extended.
Head flexed to the chest and her knees pulled up to the abdomen.
The Correct Answer is D
Choice A rationale:
Placing the client's arms raised above her head with her legs elevated on pillows (choice A) is not the correct position for a lumbar puncture. This position does not facilitate proper alignment of the spine and may hinder the procedure.
Choice B rationale:
The Trendelenburg position with the body in Sims' position (choice B) is not the correct position for a lumbar puncture. This position is not commonly used for lumbar punctures and may not provide the necessary anatomical alignment for a successful procedure.
Choice C rationale:
Placing the client prone with her arms at her side and her legs extended (choice C) is not the appropriate position for a lumbar puncture. This position does not allow for proper access to the lumbar region and may impede the procedure.
Choice D rationale:
The correct position for a lumbar puncture is to have the client flex their head to the chest and pull their knees up to the abdomen (choice D) This position maximizes the space between the lumbar vertebrae, making it easier for the provider to access the subarachnoid space for cerebrospinal fluid collection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.
Choice B rationale:
Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.
Choice C rationale:
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.
Choice D rationale:
Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common indicator of unrelieved pain in a client. It suggests that the client is uncomfortable and experiencing discomfort, which could be due to inadequate pain relief. Restlessness may manifest as frequent shifting, fidgeting, and an inability to find a comfortable position. Therefore, choice A is the correct answer as it is a reliable indicator of unrelieved pain.
Choice B rationale:
Urinary retention is not typically associated with unrelieved pain in a client with a spinal epidural for a herniated disc. Urinary retention may result from the effects of the epidural anesthesia itself but is not a specific indicator of unrelieved pain. Therefore, choice B is not the correct answer.
Choice C rationale:
Constipation is not a direct indicator of unrelieved pain related to a spinal epidural. Constipation can occur for various reasons, including medications, decreased mobility, and dietary factors. While pain may contribute to constipation indirectly, it is not a reliable and specific sign of unrelieved pain in this context. Therefore, choice C is not the correct answer.
Choice D rationale:
Difficulty swallowing is not typically associated with unrelieved pain related to a spinal epidural. It may be related to other factors, such as muscle weakness or neurological issues, but it is not a specific indicator of unrelieved pain in this situation. Therefore, choice D is not the correct answer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
