A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?
Transfer the patient to radiology.
Enforce NPO status for 4 hours.
Help the patient to a lateral position.
Administer a sedative medication.
The Correct Answer is C
A. Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B. Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C. Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D. Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.
B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.
C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.
D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.
Correct Answer is B
Explanation
A. Nuchal rigidity is a sign of meningitis but not specifically indicative of increased ICP.
B. Restlessness can be a sign of increased ICP due to reduced cerebral perfusion.
C. Photophobia is a common symptom of meningitis but does not directly indicate increased ICP.
D. Positive Kernig's sign is another indicator of meningitis but, like nuchal rigidity, it is not specific to increased ICP.
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