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 A
Explanation
The correct answer is A. "We need to check the client's urine output every hour."
Choice A rationale:
Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period.
Choice B rationale:
A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation.
Choice C rationale:
While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly.
Choice D rationale:
Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.
Correct Answer is B
Explanation
Choice A rationale:
Sarcoptes scabiei is the causative agent of scabies, a contagious skin infestation. While scabies is a communicable disease, it is typically not a reportable disease to the state health department. Scabies is usually treated at the individual or community level, and reporting to the state health department is not required.
Choice B rationale:
Neisseria gonorrhoeae is the bacterium responsible for gonorrhea, a sexually transmitted infection. Gonorrhea is a notifiable disease, and healthcare providers are required to report cases of gonorrhea to the state health department. This is because gonorrhea is a significant public health concern due to its potential complications and the need for contact tracing and prevention.
Choice C rationale:
Human papillomavirus (HPV) is a very common sexually transmitted infection, but it is typically not a reportable disease to the state health department. HPV can lead to various health issues, including genital warts and certain types of cancer. However, reporting HPV cases is not a standard practice because it is highly prevalent and usually managed at the individual level through screening and vaccination programs.
Choice D rationale:
Impetigo contagiosa is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. While it is contagious, impetigo is not typically a reportable disease to the state health department. Like scabies, impetigo is usually managed at the individual or community level, and reporting is not a standard requirement.
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