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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Observing the child's throat with a flashlight is necessary to detect any bleeding.
B. Giving the child small sips of water helps soothe the throat and promote hydration but it does not address the risk of bleeding as a complication of tonsillectomy.
C. Administering an analgesic may be indicated if the child is experiencing pain, but the throat should be assessed for any bleeding first.
D. Offering the child an ice collar may provide comfort, but assessing the throat for any bleeding is more essential.
Correct Answer is ["A","B","C","F","H"]
Explanation
Rationale:
A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.
B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.
C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.
Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.
D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.
E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.
F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.
G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.
H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.
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