Nokea
The nurse should place the client in which position?
- A. Knee-chest (genupectoral) position
- B. Sitting in an orthopneic position
- C. Side-lying position with his neck flexed
- D. Prone position with the head turned to the left side
Correct Answer: C
Rationale: The side-lying position with the neck flexed facilitates access to the lumbar spine for a lumbar puncture and helps open the intervertebral spaces.
You may also like to solve these questions
Which postoperative complication should the nurse monitor most closely after a craniotomy?
- A. Hypotension
- B. Cerebrospinal fluid leak
- C. Mild fever
- D. Constipation
Correct Answer: B
Rationale: A cerebrospinal fluid leak is a critical complication post-craniotomy, increasing infection risk and requiring immediate intervention.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
- A. Help the UAP to insert the oral airway in the mouth.
- B. Tell the UAP to stop trying to insert anything in the mouth.
- C. Take no action because the UAP is handling the situation.
- D. Notify the charge nurse of the situation immediately.
Correct Answer: B
Rationale: Inserting objects during a seizure (B) risks injury to the mouth or airway and is contraindicated. The nurse must intervene immediately. Helping the UAP (A) is unsafe, taking no action (C) neglects responsibility, and notifying the charge nurse (D) delays correction.
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak?
- A. Clients recently discharged from the hospital.
- B. Residents of a college dormitory.
- C. Individuals who visit a third world country.
- D. Employees in a high-rise office building.
Correct Answer: B
Rationale: College dormitory residents (B) are at high risk for meningococcal meningitis due to close living conditions and shared spaces. Hospital discharges (A), travel (C), or office workers (D) are less specific risks.
Which assessment finding indicates a potential spinal shock in a client with a spinal cord injury?
- A. Flaccid paralysis below the injury
- B. Spastic movements in lower limbs
- C. Intact sensation below the injury
- D. Elevated blood pressure
Correct Answer: A
Rationale: Spinal shock is characterized by flaccid paralysis and loss of reflexes below the injury level immediately after a spinal cord injury.
Which finding in a client post-stroke indicates a need for immediate intervention?
- A. Blood pressure of 180/100 mmHg
- B. Mild weakness in the right arm
- C. Difficulty finding words
- D. Fatigue after physical therapy
Correct Answer: A
Rationale: Severe hypertension post-stroke increases the risk of hemorrhage or further brain injury, requiring immediate intervention.