A patient is having 20 mL of cerebral spinal fluid removed via a lumbar puncture. What intervention is important after the procedure?

Have the patient lie flat for 6 hours.

Have the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees.

Early ambulation.

Have the patient lie flat for 1 hour, then sit up for 1 hour before ambulating.

Answer and Explanation

The Correct Answer is A

Choice A rationale
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.

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Correct Answer is A

Explanation

Choice A rationale
Herpes simplex virus encephalitis is a severe condition that requires immediate treatment. The most common medication used for this condition is acyclovir, which is administered intravenously. Acyclovir works by inhibiting the replication of the virus, thereby reducing the severity and duration of the infection.
Choice B rationale
Cyclosporine is an immunosuppressive medication that is often used to prevent organ rejection after transplantation. It is not typically used in the treatment of viral infections such as herpes simplex virus encephalitis.
Choice C rationale
Without specific information about “Medication C”, it’s difficult to provide a rationale.
However, it’s important to note that the treatment of herpes simplex virus encephalitis typically involves antiviral medications, with acyclovir being the most commonly used.
Choice D rationale
Similar to Choice C, without specific information about “Medication D”, providing a rationale is challenging. As mentioned, the standard treatment for herpes simplex virus encephalitis is acyclovir.

A. The patient has sensorineural hearing loss B. The patient is at risk for tinnitus C. The patient’s hearing is likely normal D. The patient likely has otosclerosis

Correct Answer is C

Explanation

Choice A rationale
Sensorineural hearing loss is a type of hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII). Sensorineural hearing loss can be mild, moderate, severe, or profound, and it affects the ability to hear faint sounds or understand speech. However, in the Rinne test, if the air-conducted sound is louder than the bone-conducted sound, it indicates that the patient’s hearing is likely normal.
Choice B rationale
Tinnitus is the perception of noise or ringing in the ears. It is a common problem that affects about 15 to 20 percent of people and is especially common in older adults. However, the Rinne test is not used to diagnose tinnitus. It is used to compare air and bone conduction of sound.
Choice C rationale
In a normal Rinne test, air conduction (AC) is better than bone conduction (BC). This is referred to as a positive Rinne test. If a patient reports that air-conducted sound is louder than bone-conducted sound, it suggests that the patient’s hearing is likely normal.
Choice D rationale
Otosclerosis is a condition that affects the bones in the middle ear, causing hearing loss. It is a common cause of conductive hearing loss, particularly in young adults. However, in otosclerosis, bone conduction (BC) is better than air conduction (AC), which is referred to as a negative Rinne test.

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A patient is having 20 mL of cerebral spinal fluid removed via a lumbar puncture. What intervention is important after the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client diagnosed with herpes simplex virus encephalitis. Which medication would the nurse anticipate the healthcare provider to order for treatment?

Correct Answer is A

Explanation

An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse interpret this assessment finding?

Correct Answer is C

Explanation

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