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A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
- A. Administer antihistamines to the client.
- B. Provide adequate caffeine-rich drinks to the client.
- C. Leave the client to rest and do not perform any assessments.
- D. Position the client flat as directed.
Correct Answer: D
Rationale: A client who has undergone a lumbar puncture should be positioned flat and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation.
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A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
- A. Touch nose with one finger.
- B. Close eyes and stand erect.
- C. Close eyes and discriminate between dull and sharp.
- D. Close eyes and jump on one foot.
Correct Answer: B
Rationale: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?
- A. A score of 9
- B. A score of 11
- C. A score of 12
- D. A score of 15
Correct Answer: A
Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.
A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client?
- A. Lumbar puncture
- B. Echoencephalography
- C. Nerve conduction studies
- D. EMG
Correct Answer: A
Rationale: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles.
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
- A. Using the Romberg test
- B. Observing the reaction of pupils to light
- C. Observing the client's response to painful stimuli
- D. Monitoring the client's sensitivity to temperature, touch, and pain
Correct Answer: C
Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?
- A. Cease function and shunt blood to the heart and lungs.
- B. Convert glycogen to glucose for immediate use.
- C. Produce a toxic by-product in relation to stress.
- D. Maintain a basal rate of functioning.
Correct Answer: B
Rationale: When the body is under stress, the sympathetic nervous system is activated to ready the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.