Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?

"I have a headache that gets worse when I sit up."

"I am having pain in my lower back when I move my legs."

"I feel sick to my stomach and am going to throw up."

"My throat hurts badly when I swallow and when I talk."

Answer and Explanation

The Correct Answer is A

A. A headache that worsens upon sitting up is characteristic of a post-lumbar puncture headache, indicating a potential complication related to cerebrospinal fluid leakage.

B. Pain in the lower back after the procedure can be normal and does not necessarily indicate a complication.

C. Nausea and vomiting can occur but are not specific indicators of a complication following a lumbar puncture.

D. Sore throat when swallowing and talking is not typically associated with lumbar puncture complications and may relate to other causes such as anxiety or dehydration.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Apply a nonrebreather oxygen mask. This will help increase the oxygen concentration delivered to the client's lungs and improve oxygen saturation.

B. Increase oxygen flow. Increasing the oxygen flow rate can help to further improve oxygen delivery.

C. Raise the head of the bed. This can help improve lung expansion and facilitate breathing.

D. Take and monitor vital signs. This will help assess the client's response to interventions and identify any deterioration.

E. Administer additional nebulizer treatment as prescribed. If the client's symptoms are not improving, additional nebulizer treatments may be necessary.

F. Provide client incentive spirometer and instruct on use: While incentive spirometry can be helpful in preventing atelectasis, it is not a priority in this acute situation where the client's immediate need is to improve oxygenation and reduce airway obstruction.

A. The nurse will encourage the client to walk thirty minutes every day. B. The client's family will state signs and symptoms about the disease. C. The client's blood pressure readings will be less than 160/90 mm Hg. D. The client's daily blood pressure will be less than 140/80 mm Hg this month.

Correct Answer is D

Explanation

A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.

B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.

C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.

D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall

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Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?

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Naxlex Comprehensive Predictor Exams

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is D

Explanation

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