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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Administering systemic antibiotics is essential to treat the underlying bacterial infection causing severe impetigo. This intervention helps reduce infection spread and promotes healing.

Choice B rationale

Placing mitts on the client's hands may prevent scratching, which can worsen impetigo, but it is not the primary treatment for the infection itself. Antibiotic therapy is more crucial.

Choice C rationale

Continuing antibiotics for 21 days is not a standard duration for impetigo treatment. The treatment duration typically ranges from 7 to 10 days, depending on the severity and response to treatment.

Choice D rationale

Topical antibiotics are used for mild cases of impetigo. For severe impetigo, systemic antibiotics are more appropriate and effective in managing the infection.

A. Dysfunction of the spinal accessory nerve. B. Dysfunction of the acoustic nerve. C. Dysfunction of the facial nerve. D. Dysfunction of the vagus nerve. E. Dysfunction of the vagus nerve.

Correct Answer is D

Explanation

Choice A rationale

The spinal accessory nerve (cranial nerve XI) controls the sternocleidomastoid and trapezius muscles, which are responsible for movements of the head and shoulders. Dysfunction in this nerve would not affect the gag reflex.

Choice B rationale

The acoustic nerve (cranial nerve VIII) is responsible for hearing and balance. Dysfunction in this nerve would lead to hearing loss and balance issues, not an absent gag reflex.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. Dysfunction here results in facial paralysis or weakness but not in the absence of a gag reflex.

Choice D rationale

The vagus nerve (cranial nerve X) innervates muscles of the pharynx and larynx, which are involved in swallowing and the gag reflex. Dysfunction in the vagus nerve would result in an absent gag reflex, which is why the nurse determines this as the issue.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Correct Answer is A

Explanation

A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the client has?

Correct Answer is D

Explanation

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