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 D

Explanation

A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.

B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.

C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.

D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.

A. Assess the pulses proximal to the fracture site. B. Assess the pin sites for signs of infection. C. Administer pain medication at designated intervals around the clock. D. Remove traction every shift and provide skin care.

Correct Answer is A

Explanation

A. Assessing the pulses proximal to the fracture site is crucial for evaluating blood circulation to the affected limb and detecting potential complications such as compartment syndrome.

B. While monitoring pin sites for signs of infection is important, the priority is ensuring adequate circulation.

C. Administering pain medication is essential for comfort but does not address potential complications from skeletal traction.

D. Removing traction every shift is not advisable as it can compromise the alignment and healing of the fracture.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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