A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

Transfer the patient to radiology.

Enforce NPO status for 4 hours.

Help the patient to a lateral position.

Administer a sedative medication.

Answer and Explanation

The Correct Answer is C

A.   Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B.   Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C.   Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D.   Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.

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Correct Answer is D

Explanation

A. Obtain the client's heart rate: While obtaining the client's heart rate is important in the assessment of autonomic dysreflexia, assessing for and addressing the underlying cause take precedence.

B. Administer a nitrate antihypertensive: Administering antihypertensive medication may be necessary if autonomic dysreflexia is confirmed, but it is not the first action to take. Addressing the cause of autonomic dysreflexia, such as bladder distention, is the priority.

C. Place the client in a high-Fowler's position: Elevating the client's head may help reduce blood pressure, but it does not address the underlying cause of autonomic dysreflexia. Assessing for and addressing the cause, such as bladder distention, is the priority.

D. Assess the client for bladder distention: Autonomic dysreflexia is commonly triggered by stimuli below the level of spinal cord injury, such as bladder distention. Assessing the client's bladder for distention and addressing any urinary retention or obstruction is the first action to take in managing autonomic dysreflexia.

A. A rising systolic blood pressure B. Change in mood or attention level C. Irregular respiratory rate and depth D. A bounding radial pulse

Correct Answer is B

Explanation

A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.

B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.

C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.

D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.

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A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

Correct Answer is B

Explanation

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