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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Pain at the affected joint
- Acute gout attack: Yes. During an acute gout attack, the pain is typically sudden, intense, and localized to one joint, often the big toe.
- Chronic gout: No. Chronic gout usually involves recurrent attacks over time, but the pain at any given moment may not be as intense or localized to a single joint unless there is a flare-up.
2. Low grade fever
- Acute gout attack: Yes. During an acute attack, inflammation caused by uric acid crystals can lead to mild fever (100°F to 101°F).
- Chronic gout: No. Chronic gout usually does not cause fever unless there is a secondary infection or other complicating factor.
3. Occurs in more than 1 joint
- Acute gout attack: No. Typically, an acute gout attack involves only one joint, especially the big toe (podagra).
- Chronic gout: Yes. Over time, gout can involve multiple joints, especially with untreated or poorly managed cases.
4. Renal dysfunction
- Acute gout attack: No. Acute gout attacks generally do not cause renal dysfunction.
- Chronic gout: Yes. Chronic gout can lead to kidney damage or urate nephropathy due to long-term hyperuricemia and uric acid crystal deposition in the kidneys.
5. Visible tophi
- Acute gout attack: No. Tophi, which are uric acid crystal deposits under the skin, typically appear in later stages of gout, not during an acute attack.
- Chronic gout: Yes. Visible tophi are a characteristic feature of chronic gout and occur after repeated and prolonged gout attacks, leading to the accumulation of uric acid crystals in soft tissues.
Correct Answer is A
Explanation
A. Monitoring for occult blood in urine and stool is crucial in clients with low platelet counts to detect any potential bleeding early, as they are at increased risk of bleeding due to thrombocytopenia.
B. Using a large gauge catheter may be necessary for some procedures, but it is not the priority intervention regarding the client’s current state and platelet count.
C. Removing cold and frozen foods from dietary trays does not directly address the critical concern of bleeding associated with low platelet levels.
D. While protecting bruised areas is important, it is secondary to monitoring for active bleeding, which is more critical at this stage.
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