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Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.
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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.
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
When the medical history is reviewed, which finding is most likely related to the client's diagnosis?
- A. The client had an influenza immunization in the past week.
- B. The client was bitten by a spider several days ago.
- C. The client drinks fresh, unpasteurized milk daily.
- D. The client sprayed the garden with insecticide yesterday.
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral infection or immunization, such as an influenza vaccine, which can trigger an autoimmune response.
To correctly perform the eye irrigation, the nurse instills the eye irrigant in which direction?
- A. In the lower conjunctiva toward the corneal surface
- B. From the outer canthus of the eye to the inner canthus
- C. From the nasal corner of the eye toward the temple
- D. From the margins of the eyelashes to the folds of the lids
Correct Answer: C
Rationale: Instilling irrigant from the inner canthus to the outer canthus follows the natural flow of tears, preventing contamination.
The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.
- A. Occupational Therapist (OT).
- B. Physical therapist (PT).
- C. Registered dietitian (RD).
- D. Rehabilitation physician.
- E. Social Worker (SW).
- F. Patient care tech (PCT).
Correct Answer: A,B,D,E
Rationale: OT (A) and PT (B) address functional and mobility needs, the physician (D) oversees medical care, and the social worker (E) coordinates resources. Dietitian (C) and PCT (F) are less critical for case conferences.