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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Administer an oral analgesic: Administering analgesics may provide relief from pain, but it does not address the underlying cause of the headache and stiff neck. Assessing the client's neurological status is the priority to determine the severity and potential cause of the symptoms.

B. Perform a complete blood count: While laboratory tests may be necessary to further evaluate the client, they are not the first action to take when the client presents with symptoms suggestive of a neurological emergency such as meningitis. Assessing the client's neurological status and ruling out serious conditions take precedence.

C. Evaluate the client's neurological status: Assessing the client's neurological status, including level of consciousness, motor and sensory function, and signs of meningeal irritation (such as neck stiffness), is crucial for identifying potential neurological emergencies such as meningitis and guiding further management.

D. Check the client's temperature: While obtaining vital signs, including temperature, is important in the assessment of a client with suspected meningitis, it is not the first action to take. Assessing the client's neurological status and initiating appropriate interventions based on the findings are the priority.

A. "Engage in a vigorous exercise program." B. "Plan to relax in a hot tub spa each day." C. "Implement a schedule to include periods of rest." D. "Wear an eye patch on the right eye at all times."

Correct Answer is C

Explanation

A. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.

B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.

C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.

D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.

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A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

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Naxlex Comprehensive Predictor Exams

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