A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

The correct answer is choice A.

Choice A rationale:

Count the client's radial and apical pulses simultaneously with another nurse. Rationale: In the presence of an irregular heart rate, a pulse deficit might indicate a discrepancy between the peripheral (radial) and central (apical) pulses. Counting the pulses simultaneously with another nurse helps to accurately assess this deficit. By comparing the two pulse rates, the nurse can identify if there is a difference, which might indicate inadequate circulation or irregular heartbeats that aren't effectively transmitting to the peripheral arteries.

Choice B rationale:

Calculate the client's pulse for 30 seconds and multiply by 2. Rationale: While calculating the pulse rate for 30 seconds and then multiplying by 2 is a valid method to determine the heart rate, it doesn't address the specific concern of a pulse deficit. This approach might help in assessing the overall heart rate but doesn't provide information about potential irregularities or discrepancies between peripheral and central pulses.

Choice C rationale:

Assist the client to a side-lying position. Rationale: Assisting the client to a side-lying position doesn't directly relate to the assessment of a pulse deficit. The position of the client wouldn't significantly impact the assessment of irregular heart rates or pulse deficits.

Choice D rationale:

Auscultate the area of the client's chest over the Erb's point. Rationale: Auscultating the area of the client's chest over the Erb's point is a technique used to assess heart sounds, particularly the S2 heart sound. This technique is not relevant to assessing a pulse deficit. It can provide information about heart valve function but doesn't help in evaluating a discrepancy between peripheral and central pulses.

The correct answer is choice C. Headache.

Choice A rationale:

Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.

Choice B rationale:

Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.

Choice C rationale:

Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.

Choice D rationale:

Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.