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 A

Explanation

The correct answer is choice A: "Perform muscle relaxation before bedtime."

Choice A rationale:

Suggesting to the client to "Perform muscle relaxation before bedtime" is a helpful recommendation. Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help calm the body and mind, making it easier to fall asleep.

Choice B rationale:

Advising the client to "Exercise vigorously 1 hour prior to going to bed" is not recommended. Vigorous exercise close to bedtime can actually stimulate the body and make it harder to fall asleep. Gentle, non-strenuous activities are more suitable before bedtime.

Choice C rationale:

Recommending the client to "Drink a cup of hot chocolate at bedtime" is not ideal. Hot chocolate contains caffeine, which is a stimulant that can interfere with sleep. It's better to avoid caffeine-containing beverages close to bedtime.

Choice D rationale:

Suggesting the client to "Change the time you go to sleep each day" disrupts the body's internal clock and sleep-wake cycle. Maintaining a consistent sleep schedule, even on weekends, helps regulate the body's natural sleep patterns.

A. Ego integrity vs. despair. B. Generativity vs. self-absorption. C. Identity vs. role confusion. D. Intimacy vs. isolation.

Correct Answer is A

Explanation

The correct answer is choice A. Ego integrity vs. despair.

Choice A rationale:

Erikson's Theory of Psychosocial Development outlines various stages of development that individuals go through across their lifespan. In the final stage, which occurs in late adulthood, individuals either experience a sense of ego integrity or despair. Ego integrity is characterized by a sense of fulfillment and satisfaction with one's life choices, while despair is marked by feelings of regret and a sense of unfulfillment. The older adult client expressing that their life has no purpose suggests a struggle with finding meaning and satisfaction, aligning with the ego integrity vs. despair stage.

Choice B rationale:

Generativity vs. self-absorption is a stage that occurs during middle adulthood. It involves concerns about contributing to society and the next generation. This stage is not applicable to the scenario described with an older adult who is grappling with a lack of purpose in life.

Choice C rationale:

Identity vs. role confusion is a stage that occurs during adolescence, where individuals explore their sense of self and develop their identities. This stage is not relevant to the older adult client's situation of feeling purposeless.

Choice D rationale:

Intimacy vs. isolation is a stage that typically occurs during young adulthood, where individuals seek close and meaningful relationships with others. This stage is not appropriate for the older adult's feelings of lacking purpose.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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