A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?
Fluid overload.
Diarrhea.
Headache.
Difficulty voiding.
The Correct Answer is C
The correct answer is choice C. Headache.
Choice A rationale:
Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.
Choice B rationale:
Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.
Choice C rationale:
Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.
Choice D rationale:
Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"You will need to sign a consent form before we begin the procedure." Rationale: While obtaining consent is an essential part of many medical procedures, including a bladder scan, it is not specific to the teaching related to the procedure itself. It addresses the legal and ethical aspect of the procedure but doesn't instruct the client on what to expect during the procedure.
Choice B rationale:
"I will place a gel pad directly above your pubic area before I place the probe." Rationale: This is the correct choice. Placing a gel pad above the pubic area before using the probe is an important step in ensuring proper ultrasound transmission and obtaining accurate results during a bladder scan. The gel pad helps to eliminate air gaps that could interfere with the quality of the scan.
Choice C rationale:
"You will need to hold your urine for 1 hour prior to the procedure." Rationale: Holding urine for an hour before a bladder scan might be required to ensure that the bladder is adequately filled for the scan, but it doesn't address the specific preparation related to the ultrasound procedure itself.
Choice D rationale:
"You will receive a contrast dye through an IV catheter prior to the scan." Rationale: Mentioning contrast dye and IV catheter is not relevant to a bladder scan. Contrast dye is often used in imaging studies like CT scans or angiograms, but not for a routine bladder scan. Therefore, this instruction is unrelated to the procedure in question.
Correct Answer is C
Explanation
The correct answer is Choice C: "Do you consume pork products?"
Choice C rationale: Islamic dietary laws, also known as Halal, prohibit the consumption of pork and its by-products. By asking the client about their consumption of pork products, the nurse demonstrates cultural sensitivity and ensures that the client's dietary preferences and religious practices are respected while under the facility's care.
Choice A rationale: Asking the client if they receive Holy Communion is not appropriate, as this practice is associated with Christianity rather than Islam. This question does not effectively address the client's religious preferences or needs in relation to their Islamic faith.
Choice B rationale: Inquiring about adherence to a kosher diet is not relevant, as this dietary practice is specific to Judaism and does not pertain to the Islamic faith. The nurse should be aware of the distinctions between religious practices when providing culturally competent care.
Choice D rationale: There is no general prohibition against blood transfusions in Islam. Islamic teachings generally permit medical treatments, including blood transfusions, when deemed necessary for the well-being and preservation of life. Asking the client about opposition to blood transfusions would not be the most effective way to clarify their religious preferences in the context of Islam.
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