A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
Instruct the client to expect tingling in their extremities.
Measure blood glucose every 2 hours.
Limit the client's fluid intake.
Instruct the client to lie flat.
The Correct Answer is D
Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.
Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.
Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.
Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. While there are risks associated with any surgery, thyroidectomy is not typically associated with fat embolism syndrome (FES). FES is more commonly linked to orthopedic procedures and trauma, particularly those involving long bones.
Choice B reason: Internal fixation of a fractured hip is a procedure that carries a risk for developing FES. FES is a serious and potentially life-threatening condition that occurs when fat globules enter the bloodstream and lodge within the blood vessels of the lungs or other organs. Hip fractures, especially those involving the long bones, can result in the release of fat globules into the bloodstream during the surgical repair process. Early surgical fixation is thought to reduce the risk of FES.
Choice C reason: Repair of a torn rotator cuff involves the shoulder joint and, while it is a significant surgical procedure, it is not typically associated with a high risk of FES. The rotator cuff is composed of muscles and tendons, and its repair does not usually involve manipulation of the long bones where fat embolism is more likely to occur.
Choice D reason: Tympanoplasty is a surgical procedure to repair a hole in the eardrum. It is an otologic procedure that does not involve the long bones or orthopedic manipulation. Therefore, it is not associated with a risk of developing FES.
Correct Answer is B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.
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