The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?
Client states a piercing feeling.
Physician maintains aseptic procedure.
Client states pressure relief in the head.
Cerebrospinal fluid is cloudy in nature.
The Correct Answer is D
Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.
Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.
Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.
Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Anorexia nervosa is a nutritional disorder characterized by a distorted body image and fear of weight gain, leading to an abnormally low body weight. Clients with anorexia nervosa may also engage in binge eating and purging behaviors.
Choice A is incorrect because Kwashiorkor is a type of protein-energy malnutrition caused by a severe protein deficiency.
Choice C is incorrect because Crohn's disease is a chronic inflammatory bowel disease.
Choice D is incorrect because Bulimia nervosa is a nutritional disorder characterized by binge eating and purging behaviors.
Correct Answer is B
Explanation
Provide the client with warm fluids. Shivering is the body's natural response to try to warm itself up. Providing warm fluids to the client can help to increase the client's core temperature and decrease shivering.
Choice A is incorrect because a hypothermia blanket is used to reduce the client's core temperature, which is not appropriate for a client who is shivering.
Choice C is incorrect because a light blanket may not provide enough warmth for the client who is shivering.
Choice D is incorrect because the room temperature should be kept warm to prevent the client from getting colder and shivering more.
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