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?
Position the client flat as directed.
Leave the client to rest and do not perform any assessments.
Provide caffeine-rich drinks to the client.
Avoid administering analgesic agents to the client.
Avoid administering analgesic agents to the client.
The Correct Answer is A
Choice A rationale
Positioning the client flat as directed is the priority intervention after a lumbar puncture to prevent cerebrospinal fluid (CSF) leakage, which can lead to a post-lumbar puncture headache. This position helps maintain normal CSF pressure and promotes sealing of the puncture site.
Choice B rationale
Leaving the client to rest without performing any assessments is not appropriate, as continuous monitoring is necessary to detect any complications such as bleeding or changes in neurological status. Regular assessments help ensure timely intervention if issues arise.
Choice C rationale
Providing caffeine-rich drinks is sometimes recommended to alleviate headaches caused by CSF leakage post-lumbar puncture. However, it is not the priority intervention immediately after the procedure, which focuses on positioning and monitoring.
Choice D rationale
Avoiding analgesic agents is incorrect. Pain management is an important aspect of care post-lumbar puncture, and appropriate analgesics should be administered as needed. The focus should be on positioning and monitoring, not withholding pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The parietal lobe is responsible for processing sensory information and spatial awareness, including proprioception (the sense of body position in space). Damage to the parietal lobe can affect these functions.
Choice B rationale
The temporal lobe is involved in processing auditory information and memory, not spatial awareness. Damage to this lobe would affect hearing and memory rather than proprioception.
Choice C rationale
The frontal lobe is associated with executive functions, such as decision-making, problem-solving, and motor control, but not primarily with spatial awareness. Damage to this lobe impacts cognitive and motor functions.
Choice D rationale
The occipital lobe is primarily responsible for processing visual information. Damage to this lobe affects vision rather than spatial awareness or proprioception.
Correct Answer is A
Explanation
Choice A rationale
The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.
Choice B rationale
Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.
Choice C rationale
Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.
Choice D rationale
Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.
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