The lumbar puncture was successfully completed, and the child tolerated the procedure well. The nurse will perform which of the following interventions to decrease the chance of complications:
a. Instruct the child to lie flat for a certain amount of time
b. Encourage the child to begin ambulation as soon as possible
c. Place the patient in a high Fowler's position to facilitate respirations
d. None of the above
A
The child is instructed to lay flat for a certain amount of time, in order to decrease the chance of developing a spinal headache. Ambulation and high Fowler's position would increase the likelihood of having a spinal headache.
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Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patient's current LOC?
A) The patient occasionally makes incomprehensible sounds. B) The patient's current LOC will likely become a permanent state. C) The patient may occasionally make nonpurposeful movements. D) The patient is incapable of spontaneous respirations.
A college football player is brought to the emergency room by paramedics after a blunt trauma injury received during a game
There is a high suspicion that the patient has sustained an injury to his kidneys from being tackled from behind. The emergency room nurse caring for the patient reviews the initial orders written by the physician and notes that an order has been written to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important because: A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for sodium concentrations.
The nurse is performing a physical assessment of a male client. The nurse must assess the client's sacrococcygeal area. Which of the following positions will allow the nurse to assess this area adequately?
1. Orthopneic position 2. Semi-Fowler's position 3. Lithotomy 4. On his left side with his knees drawn up
The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care?
a. Anxiety b. Fatigue c. Insomnia d. Sleep deprivation