A patient is having 20 mL of cerebral spinal fluid removed via a lumbar puncture. What intervention is important after the procedure?
Have the patient lie flat for 6 hours.
Have the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees.
Early ambulation.
Have the patient lie flat for 1 hour, then sit up for 1 hour before ambulating.
The Correct Answer is A
Choice A rationale
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Triptans, a class of medications commonly used to treat migraines, can cause vasoconstriction, or narrowing of the blood vessels. This can be problematic for patients with angina, a condition characterized by reduced blood flow to the heart. Vasoconstriction could potentially exacerbate this condition, leading to an increased risk of a heart attack. Therefore, the use of triptans may be contraindicated in patients with angina.
Choice B rationale
While asthma is a serious condition that requires careful management, it is not typically considered a contraindication for the use of triptans. Triptans work primarily on the blood vessels in the brain and do not typically interact with the bronchial tubes affected by asthma.
Choice C rationale
Age alone is not typically a contraindication for the use of triptans. However, older adults may have a higher risk of certain health conditions, such as heart disease, which could make the use of triptans more risky. It’s important for healthcare providers to consider the overall health status of the patient, not just their age, when deciding whether to prescribe triptans.
Choice D rationale
While stress can certainly exacerbate migraines, it is not typically a contraindication for the use of triptans. Triptans are designed to relieve the pain and other symptoms of migraines, regardless of their cause. If a patient’s migraines are triggered by stress, it may be beneficial to explore stress management techniques in addition to medication.
Correct Answer is C
Explanation
Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.
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