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The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client regarding care postprocedure?
- A. Instruct that all invasive procedures require a written permission.
- B. Explain that this allows analysis of a sample of the cerebrospinal fluid.
- C. Tell the client to increase fluid intake to 300 mL for the next 48 hours.
- D. Discuss that lying supine with the head flat will prevent all hematomas.
Correct Answer: C
Rationale: Post-lumbar puncture, increasing fluid intake (C) helps replace CSF and prevent headaches. Consent (A) is preoperative, CSF analysis (B) explains purpose, and lying flat (D) prevents headaches, not hematomas.
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Which discharge instruction is most appropriate following the positron emission tomography scan?
- A. Take a mild sedative tonight.
- B. Increase your fluid intake.
- C. Avoid excessive sitting.
- D. Report signs of a fever.
Correct Answer: B
Rationale: Increasing fluid intake helps flush the radioactive tracer used in the PET scan from the body.
The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply.
- A. Assess for deep vein thrombosis.
- B. Administer intravenous anticoagulant.
- C. Monitor intake and output strictly.
- D. Apply warm compresses to the eyes.
- E. Perform passive range-of-motion exercises.
Correct Answer: A,C,E
Rationale: Assessing DVT (A), monitoring intake/output (C), and passive ROM (E) prevent complications. Anticoagulants (B) increase bleeding risk, and warm compresses (D) are not indicated.
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client’s spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?
- A. “Plasmapheresis removes excess fluid from the bloodstream.”
- B. “Plasmapheresis will increase the protein levels in the blood.”
- C. “Plasmapheresis removes circulating antibodies from the blood.”
- D. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”
Correct Answer: C
Rationale: Aquapheresis or dialysis, not plasmapheresis, will remove excess fluid from the blood. Plasmapheresis does not increase protein levels in the blood. Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client. Plasmapheresis does not involve infusing lipoproteins.
The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?
- A. MRIs are loud but there will not be any invasive procedure done.'
- B. You’re scared. Tell me about what is scaring you.'
- C. This is the least thing to be scared about—there will be worse.'
- D. I can call the MRI tech to come and talk to you about the scan.'
Correct Answer: B
Rationale: Reflecting the client’s fear (B) encourages expression of concerns, fostering therapeutic communication. Other options provide information (A, D) or minimize feelings (C).
The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
- A. Tell the client to take any routine antiseizure medication prior to the EEG.
- B. Tell the client not to eat anything for eight (8) hours prior to the procedure.
- C. Instruct the client to stay awake for 24 hours prior to the EEG.
- D. Explain to the client that there will be some discomfort during the procedure.
Correct Answer: A
Rationale: Taking routine antiseizure medications (A) ensures therapeutic levels during the EEG, avoiding seizures that could skew results. Fasting (B) is unnecessary, sleep deprivation (C) may be used in specific cases but not routinely, and EEGs are painless (D).