A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?
Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Keep the infant NPO for 6 hr prior to the procedure.
Hold the infant's chin to his chest and knees to his abdomen during the procedure.
Place the infant in an infant seat for 2 hr following the procedure.
The Correct Answer is C
The correct answer is: c. Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
Choice A: Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Applying a eutectic mixture of lidocaine and prilocaine (EMLA) cream can help reduce pain during procedures like lumbar punctures. However, it typically needs to be applied 30 to 60 minutes before the procedure to be effective. Applying it only 15 minutes prior would not provide adequate analgesia.
Choice B: Keep the infant NPO for 6 hr prior to the procedure.
Keeping an infant NPO (nothing by mouth) for 6 hours is generally recommended before procedures requiring sedation or anesthesia to reduce the risk of aspiration. However, lumbar punctures do not typically require such prolonged fasting, especially in infants, unless sedation is planned.
Choice C: Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
This is the correct positioning for a lumbar puncture in infants. The infant should be held in a curled-up position, with the chin to the chest and knees to the abdomen, to maximize the space between the vertebrae and allow easier access to the lumbar region. This position helps to stabilize the infant and reduce movement during the procedure.
Choice D: Place the infant in an infant seat for 2 hr following the procedure.
Post-procedure care for a lumbar puncture typically involves monitoring the infant for any signs of complications, such as headache or infection. Placing the infant in an infant seat for 2 hours is not a standard recommendation. Instead, the infant should be observed and allowed to rest comfortably.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: A video game is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it does not address the child's feelings or concerns about the injection. A video game may provide distraction or entertainment, but it does not help the child cope with or understand their condition.
Choice B: A period of play in the playroom is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it does not address the child's feelings or concerns about the injection. A period of play in the playroom may provide socialization or stimulation, but it does not help the child cope with or understand their condition.
Choice C: A storybook about a 4-year-old child is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection unless the storybook is specifically about diabetes mellitus and insulin injections. A storybook about a 4-year-old child may provide identification or imagination, but it does not help the child cope with or understand their condition.
Choice D: A needleless syringe and a doll is a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it allows the child to express their feelings and concerns about the injection through role-playing and simulation. A needleless syringe and a doll can help the child cope with and understand their condition by providing mastery, control, and education.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because the loss of a parent is not the priority risk factor for suicide completion. Loss of a parent is a stressful life event that may cause grief, depression, or anxiety in an adolescent, but it does not necessarily increase the risk of suicide completion. However, the loss of a parent may be associated with other risk factors such as low self-esteem, poor coping skills, or social isolation, which can contribute to suicidal ideation or behavior.
Choice B reason: This choice is incorrect because a history of substance abuse is not the priority risk factor for suicide completion. History of substance abuse is a behavioral problem that may impair the judgment, mood, or impulse control of an adolescent, but it does not necessarily increase the risk of suicide completion. However, a history of substance abuse may be associated with other risk factors such as mental illness, family conflict, or legal trouble, which can contribute to suicidal ideation or behavior.
Choice C reason: This choice is correct because a previous suicide attempt is the priority risk factor for suicide completion. Previous suicide attempt is a clear indicator of suicidal intent and capability, and it increases the likelihood of future attempts and completion. According to the American Foundation for Suicide Prevention (AFSP), about 40% of people who die by suicide have a history of previous attempts. Therefore, assessing and addressing previous suicide attempts is essential to prevent further harm and save lives.
Choice D reason: This choice is incorrect because active psychiatric disorder is not the priority risk factor for suicide completion. Active psychiatric disorder is a mental health condition that may affect the thoughts, feelings, or behaviors of an adolescent, but it does not necessarily increase the risk of suicide completion. However, active psychiatric disorder may be associated with other risk factors such as hopelessness, helplessness, or isolation, which can contribute to suicidal ideation or behavior.
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