Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?
"I have a headache that gets worse when I sit up."
"I am having pain in my lower back when I move my legs."
"I feel sick to my stomach and am going to throw up."
"My throat hurts badly when I swallow and when I talk."
The Correct Answer is A
A. A headache that worsens upon sitting up is characteristic of a post-lumbar puncture headache, indicating a potential complication related to cerebrospinal fluid leakage.
B. Pain in the lower back after the procedure can be normal and does not necessarily indicate a complication.
C. Nausea and vomiting can occur but are not specific indicators of a complication following a lumbar puncture.
D. Sore throat when swallowing and talking is not typically associated with lumbar puncture complications and may relate to other causes such as anxiety or dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.
B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.
C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.
D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Based on history and assessment data, the nurse should prioritize activity intolerance as the priority problem for this client, as evidenced by the client's statement "I just can't catch my breath."
Rationale:
- Activity intolerance: The client's shortness of breath and wheezing indicate impaired gas exchange and reduced oxygenation, which limits their ability to engage in physical activity.
- Anxiety: While anxiety can exacerbate asthma symptoms, the immediate priority is to address the physiological issue of impaired gas exchange.
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