A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

Monitor the puncture site for hematoma.

Elevate the client’s head of bed.

Insert a urinary catheter.

Encourage fluid intake.

Apply a cervical collar to the client.

Answer and Explanation

Correct Answer : A,D

Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale

Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.

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Correct Answer is C

Explanation

Choice A rationale
Osteoarthritis is not caused by inflammation that affects both joints and other body tissues. This description is more characteristic of rheumatoid arthritis, which is an autoimmune disease that causes systemic inflammation.
Choice B rationale
Osteoarthritis does not occur in phases with crystal deposits. This description is more characteristic of gout, which involves the deposition of urate crystals in joints and soft tissues.
Choice C rationale
Osteoarthritis is primarily due to the aging process and results in the disintegration of cartilage in a joint. This leads to pain, stiffness, and reduced joint function.
Choice D rationale
Osteoarthritis is not due to the loss of calcium in the bones. This description is more characteristic of osteoporosis, which is a condition that weakens bones and increases the risk of fractures.

A. Blood glucose levels. B. Gallbladder studies. C. Liver function tests. D. Thyroid function studies.

Correct Answer is C

Explanation

Choice A rationale
Monitoring blood glucose levels is not specifically required for clients taking pyrazinamide. This medication does not typically affect blood glucose levels.
Choice B rationale
Gallbladder studies are not required for clients taking pyrazinamide. This medication does not typically affect the gallbladder.
Choice C rationale
Liver function tests are required for clients taking pyrazinamide. This medication can cause hepatotoxicity, so regular monitoring of liver function is essential to detect any potential liver damage early.
Choice D rationale

Thyroid function studies are not required for clients taking pyrazinamide. This medication does not typically affect thyroid function.

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A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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