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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "I know that I can change my advance directives if I need to in the future."
Choice A rationale:
This statement indicates an understanding of advance directives. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in case they become unable to make decisions themselves. It's important for clients to know that they can update or change their advance directives if their wishes or circumstances change over time.
Choice B rationale:
The statement that the health care surrogate will make decisions as soon as the power of attorney is signed is not accurate. Generally, a health care surrogate's authority to make decisions comes into effect when the primary individual is no longer able to make decisions themselves. Signing a power of attorney alone does not grant immediate decision-making power to the surrogate.
Choice C rationale:
The family generally cannot overrule the decisions made by a designated health care surrogate. Once an individual designates a surrogate and provides clear instructions through advance directives, the surrogate's decisions are legally binding and typically override the family's input.
Choice D rationale:
Advance directives are not universally valid across states. Laws and regulations regarding advance directives can vary significantly from state to state. It's important for clients to understand that if they relocate, they may need to update their advance directives to comply with the laws of the new state.
Correct Answer is B
Explanation
The correct answer is: B. Latex.
Choice A reason: Allergy to eggs is primarily a concern when it comes to vaccinations, such as the influenza vaccine, which may contain egg protein. In the context of IV therapy, egg allergies are not typically associated with direct contraindications or precautions. However, it’s important to note that some medications or vaccines may contain egg proteins, which could be relevant in certain medical procedures, but not usually in standard IV therapy.
Choice B reason: Latex allergies are particularly relevant in a hospital setting where latex is commonly found in various medical supplies, including gloves, catheters, and IV tubing. A latex allergy can cause severe reactions, including anaphylaxis, which is a life-threatening condition. Therefore, it is crucial for healthcare providers to be aware of a patient’s latex allergy to avoid exposure during medical procedures, including IV therapy.
Choice C reason: Seafood allergies are generally related to the ingestion of seafood and do not typically pose a risk in the context of IV therapy. The concern about iodine in contrast media, which is sometimes mistakenly linked to seafood allergies, is not relevant to standard IV therapy solutions.
Choice D reason: Bee sting allergies are significant when a patient is exposed to bee venom, which can cause anaphylaxis. In the context of IV therapy, a bee sting allergy is not typically a concern unless the therapy involves venom immunotherapy or the patient has had a recent bee sting that might complicate their medical condition.
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