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. Assessing the risk of self-harm or suicide is the top priority when caring for a patient with major depressive disorder. It allows the nurse to intervene immediately if there's a risk of harm.
B. While group therapy can be beneficial for individuals with depression, it's not the first priority when assessing for safety concerns.
C. Administering antidepressants may be part of the treatment plan, but it's essential to assess the immediate risk of self-harm before proceeding with medication administration.
D. Assisting with activities of daily living is important, but it's not the first action to take when assessing for safety in a patient with major depressive disorder.
Correct Answer is A
Explanation
Rationale:
A. Providing for periods of rest is important to conserve energy in children with heart failure.
B. Increasing the oxygen flow rate until cyanosis resolves may not be appropriate without medical guidance.
C. Digoxin should not be withheld without consulting the healthcare provider. It is essential to follow the prescribed regimen and contact the provider if there are concerns about the child's pulse rate.
D. Weighing the child once each month may not be frequent enough for monitoring fluid status in a child with heart failure. More frequent weight monitoring may be necessary as per the healthcare provider's recommendations.
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