A nurse is caring for a child who has had a lumbar puncture. The nurse should monitor the child for which of the following complications?

Nuchal rigidity when standing

Double vision

Headache

Pain in the posterior iliac crest

Answer and Explanation

The Correct Answer is C

Rationale:

A. Nuchal rigidity when standing may indicate meningitis, but it is not a common complication of lumbar puncture itself.

B. Double vision is not a typical complication of lumbar puncture and suggests other neurological issues.

C. Headache is a common complication of lumbar puncture, occurring due to leakage of cerebrospinal fluid (CSF) from the puncture site. It is often described as positional, worsening when the patient sits or stands upright and improving when lying down.

D. Pain in the posterior iliac crest is not a typical complication of lumbar puncture and may indicate musculoskeletal issues unrelated to the procedure.

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Correct Answer is A

Explanation

Rationale:

A. Allowing the child to sit on the parent's lap can provide comfort and support during the procedure.

B. While the electrocardiogram (ECG) machine may have alarms, they are not typically related to abnormal heart rhythms during the procedure.

C. ECG leads are typically placed on the chest, not the back.

D. The duration of an ECG is relatively short, usually only a few minutes, so stating that it will take at least 30 minutes may cause unnecessary concern for the parent.

A. Inform the client to contact the pharmacy regarding any questions related to the medication. B. Provide instructions to the client's parent with the client present. C. Instruct the client's parents to write down the information that is being provided. D. Ask how the client prefers to learn new information.

Correct Answer is D

Explanation

Rationale:

A. While informing the client to contact the pharmacy is appropriate, it does not address the immediate need for understanding the medication.

B. Providing instructions to the client's parent may not respect the adolescent's autonomy and privacy regarding their healthcare.

C. Instructing the client's parents to write down the information may not involve the adolescent in the learning process or address their individual needs.

D. Asking how the client prefers to learn new information demonstrates respect for the adolescent's autonomy and preferences, facilitating effective communication and understanding.

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A nurse is caring for a child who has had a lumbar puncture. The nurse should monitor the child for which of the following complications?

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