A nurse is caring for a client who is undergoing a lumbar puncture.

Which of the following is the priority action for the nurse to take to maintain privacy for the client?

Pull the curtains around the client's bed.

Ask family members to leave the room.

Use sterile drapes to cover the client.

Close the door to the client's room.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Pulling the curtains around the client’s bed ensures privacy during the procedure.
Choice B rationale:
Asking family members to leave the room might be necessary, but it’s not the priority action.
Choice C rationale:
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
Choice D rationale:
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.

A. Obtain impedance plethysmography. B. Apply cold therapy to the affected leg. C. Obtain a venous duplex ultrasound. D. Monitor Homan's sign.

Correct Answer is C

Explanation

Choice A rationale:
Impedance plethysmography is a test that uses electrical signals to measure blood flow and can be used to detect deep vein thrombosis (DVT). However, it is not the first-line diagnostic tool for DVT.
Choice B rationale:
Cold therapy can help reduce inflammation and pain, but it is not a diagnostic measure for DVT.
Choice C rationale:
Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
Choice D rationale:
Homan’s sign is a physical examination finding that was traditionally used to diagnose DVT, but it is not reliable or specific.

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A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse to take to maintain privacy for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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A nurse is caring for a client who is undergoing a lumbar puncture.

Which of the following is the priority action for the nurse to take to maintain privacy for the client?