The nurse is assisting the neurologist with a lumbar puncture on a patient with possible meningitis. Which post-procedure teaching point is the highest priority for the patient?
Maintain a flat lying position for 14 hours following the procedure.
Muscular discomfort is expected after being in a curled position for a period of time.
Resume oral intake immediately after the procedure.
Mild pain is expected at the needle insertion site.
The Correct Answer is A
Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.
Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.
Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.
Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decreased hematocrit and hemoglobin indicate anemia, which is a condition where the blood does not carry enough oxygen to the tissues. This can cause symptoms such as confusion, restlessness, fatigue, and weakness in older adults.
Choice B reason: Increased erythrocyte count, or polycythemia, is a condition where the blood has too many red blood cells. This can cause the blood to become thick and viscous, which can impair blood flow and oxygen delivery. However, this is not the best explanation for the patient's confusion and restlessness, as polycythemia usually causes symptoms such as headache, dizziness, itching, and flushing.
Choice C reason: Normochromic red blood cells are red blood cells that have a normal color and hemoglobin content. This is not a finding that would explain the patient's confusion and restlessness, as it indicates a normal red blood cell function.
Choice D reason: Decreased thrombocytes, or platelets, are blood cells that help with clotting. This is a finding that would increase the risk of bleeding, but not the risk of confusion and restlessness. Decreased thrombocytes can cause symptoms such as bruising, bleeding gums, nosebleeds, and petechiae.
Correct Answer is C
Explanation
Choice A reason: Sudden unconsciousness, unresponsiveness, and apnea are not typical symptoms of a brain tumor. They are more likely to indicate a stroke, seizure, or cardiac arrest.
Choice B reason: Increased temperature, blood pressure, heart rate, and respirations are not specific symptoms of a brain tumor. They are more likely to indicate an infection, inflammation, or stress.
Choice C reason: Changes in vision and personality, and headache upon awakening are common symptoms of a brain tumor. They are caused by the pressure of the tumor on the brain tissue and the cranial nerves.
Choice D reason: Fever, increased white blood cell count, and decreased appetite are not typical symptoms of a brain tumor. They are more likely to indicate a systemic infection or malignancy.
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