Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?
Lie flat.
Lie on left side.
Stay in semi-Fowler position.
Ambulate in the room with assistance.
The Correct Answer is A
A. Lie flat:
This option involves instructing the patient to lie flat on their back without elevating their head. Lying flat helps to maintain consistent pressure in the spinal canal, reducing the likelihood of CSF leakage from the puncture site. This position is commonly recommended after a lumbar puncture to prevent or minimize the occurrence of post-lumbar puncture headaches (PLPH).
B. Lie on left side:
This option involves instructing the patient to lie on their left side. While lying on the left side may provide some relief by reducing pressure on the lumbar puncture site, it is not typically recommended immediately after the procedure to prevent PLPH. Lying flat is generally preferred to minimize changes in CSF pressure and reduce the risk of headache.
C. Stay in semi-Fowler position:
The semi-Fowler position involves elevating the head of the bed at a 30-45 degree angle. This position is not typically recommended immediately after a lumbar puncture because it may increase CSF leakage and pressure changes, potentially exacerbating the risk of developing a headache.
D. Ambulate in the room with assistance:
Ambulating shortly after a lumbar puncture is not typically recommended as it may increase the risk of developing a headache. Movement and changes in posture can exacerbate CSF leakage and pressure changes at the puncture site, leading to the development of post-lumbar puncture headaches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bradycardia, hypertension, and widening pulse pressure
This combination of symptoms is characteristic of Cushing's triad. Bradycardia (slow heart rate), hypertension (elevated blood pressure), and widening pulse pressure (difference between systolic and diastolic blood pressure) are indicative of increased ICP, specifically resulting in the compression of brain structures that regulate vital functions.
B. Widening pulse pressure, headache, and seizure
While headache and seizure may occur in patients with increased ICP, widening pulse pressure alone is not sufficient to meet the criteria of Cushing's triad. The presence of bradycardia and hypertension, along with widening pulse pressure, is more indicative of Cushing's triad.
C. Hypertension, tachycardia, and headache
Hypertension and headache may occur in patients with increased ICP, but the absence of bradycardia and widening pulse pressure makes this option less characteristic of Cushing's triad.
D. Hypotension, tachycardia, and narrowing pulse pressure
Hypotension (low blood pressure) and narrowing pulse pressure are not typically associated with Cushing's triad. Tachycardia (rapid heart rate) may occur in response to increased ICP, but it is usually accompanied by bradycardia rather than hypotension.
Correct Answer is A
Explanation
A. Nystagmus:
Nystagmus is an involuntary, rhythmic movement of the eyes, which can be rapid and jerky. It is a common neurological manifestation of phenytoin toxicity. Patients experiencing phenytoin toxicity may exhibit horizontal or vertical nystagmus, which can be detected upon physical examination.
B. Strabismus:
Strabismus, also known as crossed eyes or squint, refers to a misalignment of the eyes. While strabismus can have various causes, it is not typically associated with phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus.
C. Blurry vision:
Blurry vision, or visual disturbances, can occur in patients experiencing phenytoin toxicity. However, it is a non-specific symptom and can be observed in various other conditions as well. Patients with phenytoin toxicity may experience blurry vision, double vision (diplopia), or other visual disturbances due to the effects of the medication on the central nervous system.
D. Amblyopia:
Amblyopia, also known as lazy eye, is a condition characterized by reduced vision in one or both eyes. It is typically associated with visual development during childhood and is not directly related to phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus or other neurological manifestations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today