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","D","E"]
Explanation
Rationale:
A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.
B. Weight gain or fluid retention is more common in children with heart failure.
C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.
D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.
E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.
Correct Answer is B
Explanation
Rationale:
A. This response is beyond the child’s understanding.
B. Curiosity about what happened to the sibling's body is a common reaction in preschool-age children and can be considered age-appropriate.
C. Preschool-age children may struggle to give a logical explanation for death due to their limited cognitive development and understanding of abstract concepts.
D. Feeling responsible for the sibling's death is not an age-appropriate response for a preschool-age child. Young children may experience guilt but usually do not attribute death to their actions or feelings of responsibility.
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