The nurse assesses four clients according to their diagnoses. Which client diagnosis does the nurse associate with the need for a lumbar puncture?
1. Lumbar spinal stenosis
2. Hereditary coagulopathy
3. Acute bacterial meningitis
4. Increased intracranial pressure
3
3. The provider performs a lumbar puncture on the client with bacterial meningitis to obtain a sample of cerebrospinal fluid for culture.
1. Lumbar puncture is contraindicated for the client with spinal stenosis because spinal stenosis is usually caused by the abnormal movements caused by bone spurs. Bone spurs distort the shape of the vertebrae and increase the risk of client injury during the procedure.
2. A coagulopathy is a contraindication to lumbar puncture because the client is at high risk for bleeding into the subarachnoid space.
4. Lumbar puncture on a client with increased intracranial pressure increases the risk of supratentorial herniation and poses a life-threatening risk to the client.
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1. Ask the parent to leave the examination room as this is probably the cause of the child's nervousness. 2. Assure the child that you will not hurt her. 3. Say to the child: "Tell me why you are so nervous." 4. Explain to the child what you are doing in terms the child can understand. Explain the equipment and, when possible, let the child handle the equipment first.
The nurse is talking with the family of a mentally ill client who lives with them. The client is being admitted to the inpatient psychiatric unit. What is the priority information to gather from the family?
1. Whether the client had a flu shot recently 2. The number of medications prescribed for the client 3. How the client's symptoms are expressed at home 4. The type of soap the client prefers to use
A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How should the nurse respond?
a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."
To check the IV flow rate, which is correct?
a. Count the number of drops in 30 seconds and multiply by 2. b. Count the number of drops in 1 minute. c. Check how much fluid remains in the IV bag. d. Note if the rate seems too fast or too slow.