A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Fluid overload.

Diarrhea.

Headache.

Difficulty voiding.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Headache.

Choice A rationale:

Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.

Choice B rationale:

Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.

Choice C rationale:

Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.

Choice D rationale:

Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.

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Correct Answer is D

Explanation

The correct answer is choice D: Choose a private room for the interview.

Choice D rationale:

Opting for a private room for the interview is essential when interacting with a client who uses a hearing aid. This choice helps minimize background noise and distractions, ensuring effective communication between the nurse and the client. Adequate lighting and minimizing auditory interference are crucial for clients with hearing difficulties.

Choice A rationale:

Sitting beside the client is a considerate approach, but it may not directly address the hearing aid user's needs. The focus should be on creating an optimal environment for communication, which includes minimizing auditory and visual obstacles.

Choice B rationale:

Speaking slowly and loudly to the client is not the most appropriate approach. While speaking clearly and facing the client is recommended, speaking loudly may distort sounds and hinder understanding for clients with hearing aids.

Choice C rationale:

Dimming the lights in the client's room is not necessary for addressing the needs of a client with a hearing aid. Adequate lighting is important for lip-reading and effective communication, especially for clients who rely on visual cues.

A. "It must be difficult facing this type of surgery.” B. "Other clients who have had this surgery have done just fine.” C. "This facility is known for providing excellent care for people who need this type of surgery.” D. "I can request a sleeping pill if you think that will help.”

Correct Answer is A

Explanation

The correct answer is choice a. "It must be difficult facing this type of surgery.”

Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.

Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.

Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.

Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.

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A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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