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 C
Explanation
Choice A rationale:
Epinephrine is not typically used to treat nausea. Nausea is usually managed with antiemetic medications.
Choice B rationale:
Epinephrine is not used to treat hand tremors. Hand tremors may be related to various conditions, and their management would depend on the underlying cause.
Choice C rationale:
The correct manifestation that epinephrine can help treat is "Swelling of the lips." Epinephrine is commonly used to treat severe allergic reactions (anaphylaxis), which can cause swelling of the lips, tongue, and throat. Epinephrine helps to reverse these symptoms by constricting blood vessels and opening the airways.
Choice D rationale:
Epinephrine is not used to treat hyperglycemia. Hyperglycemia is managed with insulin or other antidiabetic medications, not epinephrine.
Correct Answer is D
Explanation
Choice A rationale:
Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.
Choice B rationale:
A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.
Choice C rationale:
A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.
Choice D rationale:
Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.
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