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.

Answer and Explanation

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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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:Frequent exposure to low-volume noise is not typically a risk factor for hearing loss. Hearing loss is more commonly associated with prolonged exposure to high-volume noise, which can damage the delicate structures within the ear.

Choice B reason: Chronic infections of the middle ear, such as chronic otitis media, can lead to hearing loss. These infections can cause persistent inflammation and fluid buildup, which may damage the middle ear structures over time, leading to conductive hearing loss.

Choice C reason: Perforation of the eardrum, or a ruptured eardrum, can result in hearing loss. The eardrum is essential for the proper conduction of sound waves to the inner ear. A perforation disrupts this process and can reduce hearing ability until the eardrum heals or is surgically repaired.

Choice D reason: Being born with a high birth weight is not a known risk factor for hearing loss. Hearing loss at birth is more commonly associated with genetic factors, prenatal and perinatal infections, and complications during birth.

Choice E reason: The use of a loop diuretic can be a risk factor for hearing loss. These medications can have ototoxic effects, especially when administered in high doses or with rapid intravenous infusion, potentially leading to temporary or permanent hearing loss.

A. Tongue blade B. NG tube C. Oral airway D. Wrist restraints

Correct Answer is C

Explanation

Choice A reason : A tongue blade should not be placed in the mouth during a seizure as it can cause injury or obstruct the airway.

Choice B reason: An NG tube, or nasogastric tube, is not typically required in the immediate management of seizures and should not be inserted during an active seizure due to the risk of injury.

Choice C reason: An oral airway may be used to maintain a patent airway during a postictal state if the client is unable to maintain their own airway.

Choice D reason: Wrist restraints are not routinely recommended for clients with seizure disorders as they can cause injury during a seizure. Safe environment and proper positioning are preferred to prevent injury.

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A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Nursing Test Bank

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