The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Client states a piercing feeling.

Physician maintains aseptic procedure.

Client states pressure relief in the head.

Cerebrospinal fluid is cloudy in nature.

Answer and Explanation

The Correct Answer is D

Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.

Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.

Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.

Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.

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Correct Answer is A

Explanation

Monitoring the rate of IV infusions. In clients with diabetes insipidus, fluid therapy is essential to restore hydration levels. It is important to monitor the rate of IV infusion to avoid rapid administration of fluids, which can lead to fluid overload and pulmonary edema. Therefore, monitoring the rate of IV infusions is the most important intervention for this client.

Choice B, weighing the client daily, is incorrect because it is not the most important intervention for this client. While daily weighing is important for monitoring fluid balance, monitoring the rate of IV infusion is more critical.

Choice C, measuring the urine output every 30 minutes, is incorrect because although it is important to monitor urine output in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.

Choice D, measuring the fluid intake, is incorrect because although it is important to monitor fluid intake in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.

A. Hearing loss. B. Nystagmus. C. Vertigo. D. Tinnitus. E. Loss of vision.

Correct Answer is ["A","C","D"]

Explanation

Meniere's disease is a disorder of the inner ear characterized by episodes of vertigo, hearing loss, tinnitus, and a feeling of fullness or pressure in the ear. Nystagmus is not a common symptom of Meniere's disease. Nystagmus is a rhythmic oscillation of the eyes and may be present in other conditions such as vestibular disorders, drug toxicity, or brainstem lesions.

Choice B, nystagmus, is incorrect because although nystagmus can occur in other vestibular disorders, it is not a common symptom of Meniere's disease.

Choice E, loss of vision, is incorrect because Meniere's disease affects the inner ear and does not typically cause vision loss.

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The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetes insipidus is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for the client?

Correct Answer is A

Explanation

You are taking care of a client who suffers from Meniere's disease. On assessment, you note what common symptoms of this disorder? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

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