Nokea
The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurses most appropriate action?
- A. Position the patient prone.
- B. Position the patient supine with the head of bed flat.
- C. Position the patient left side-lying.
- D. Administer acetaminophen as ordered.
Correct Answer: A
Rationale: Prone positioning after lumbar puncture minimizes cerebrospinal fluid leakage, reducing headache risk. Supine or side-lying positions are less effective, and acetaminophen is not a preventive measure.
You may also like to solve these questions
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?
- A. Rigidity
- B. Flaccidity
- C. Clonus
- D. Ataxia
Correct Answer: C
Rationale: Clonus is characterized by rhythmic muscle contractions, such as foot beating after dorsiflexion, indicating hyperactive reflexes. Rigidity is increased muscle tone, flaccidity is lack of tone, and ataxia is uncoordinated movement.
A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patients health problem?
- A. Cerebellar dysfunction
- B. A lesion in the pons
- C. Dysfunction of the medulla
- D. A hemorrhage in the midbrain
Correct Answer: A
Rationale: The cerebellum coordinates movement and balance, so dysfunction causes uncoordinated gait. Pons, medulla, and midbrain lesions affect other functions like respiration or eye movement.
A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?
- A. What are the patients and familys expectations of the test
- B. Whether the patients family had any questions about why the test was necessary
- C. Whether the patient has had any complications of the test
- D. Whether the patient understood accurately why the test was done
Correct Answer: C
Rationale: Post-lumbar puncture follow-up checks for complications like headaches or infection. Expectations and understanding should be addressed before the procedure.
A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient?
- A. The test will temporarily limit blood flow through the brain.
- B. An allergy to iodine precludes getting the radio-opaque dye.
- C. The patient will need to endure loud noises during the test.
- D. The test may result in dizziness or lightheadedness.
Correct Answer: D
Rationale: PET scans may cause dizziness or lightheadedness due to tracer inhalation. Blood flow is not limited, iodine allergy applies to CT/MRI, and noise is an MRI concern.
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
- A. Adrenal crisis
- B. Hypothalamic collapse
- C. Sympathetic storm
- D. Cranial nerve deficit
Correct Answer: C
Rationale: Sympathetic storm, triggered by brain injury, causes altered consciousness, elevated vital signs, diaphoresis, and agitation due to sympathetic overstimulation. Other options do not fully explain these symptoms.