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?
Head flexed to the chest and her knees pulled up to the abdomen
Arms raised above her head with her legs elevated on pillows
Prone with her arms at her side and her legs extended
Trendelenburg with her body in Sims' position
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Since the client's respiratory rate is labored and there are abnormal breath sounds (crackles and wheezes), it is important to assess their oxygen saturation level. This finding can help determine the adequacy of their oxygenation and whether intervention is needed.
The client's labored respirations, along with the presence of abnormal breath sounds, indicate potential respiratory distress. Assessing their respiratory rate is crucial to determine the severity of the respiratory compromise and the need for immediate intervention.
The nurse's note mentions that the client is restless and not following commands. This change in the level of consciousness may indicate a decline in neurological status and should be promptly evaluated.
The other options listed (tremors in hands, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.
Correct Answer is D
Explanation
Swelling of the lips
The nurse should reinforce with the client that the epinephrine auto-injector can help treat swelling of the lips. Epinephrine is a medication commonly used to treat severe allergic reactions, also known as anaphylaxis. Swelling of the lips is one of the hallmark manifestations of an allergic reaction.
Epinephrine acts quickly to reverse the allergic response by constricting blood vessels, relaxing smooth muscles, and reducing swelling and inflammation.
Nausea in (option A) is incorrect: Nausea can have various causes, and epinephrine is not specifically indicated for treating this symptom.
Hyperglycemia in (option B) is incorrect: Epinephrine can potentially increase blood glucose levels, so it is not used to treat hyperglycemia.
Hand tremors in (option C) is incorrect: Epinephrine can cause tremors as a side effect, so it is not used to treat hand tremors.
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