A client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

Correct Answer: D

Rationale: The correct answer is D. During a lumbar puncture, the client should be positioned in a side-lying position with the legs pulled up and head bent down onto the chest. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to access the lumbar area. Placing the legs up also helps to widen the spaces between the vertebrae, making it easier to insert the needle without damaging the spinal cord. The head bent down onto the chest helps to round the back, further increasing the space between the vertebrae. Choice A is incorrect because placing a pillow under the hip does not provide the necessary positioning for a lumbar puncture. Choice B is incorrect as the prone position with a pillow under the abdomen would not facilitate access to the lumbar area. Choice C is incorrect as the Trendelenburg's position is not recommended for lumbar punctures as it can increase intracranial pressure.

Correct Answer: C

Rationale: The correct answer is C, unilateral edema. This finding is most concerning as it may indicate a blockage or dysfunction in the lymphatic or venous system, potentially leading to serious conditions like deep vein thrombosis. In contrast, A and D are normal findings indicating good peripheral circulation, while B is also normal and indicates balanced blood flow.

Correct Answer: B

Rationale: The correct answer is B: Refer the patient for further evaluation. This is because the lesion with irregular borders and varied colors raises concern for possible skin cancer. Referring the patient for further evaluation by a dermatologist is crucial to determine the nature of the lesion and initiate appropriate treatment. Documenting it as a normal finding (choice A) is incorrect as it may delay necessary intervention. Applying an antibiotic ointment (choice C) is not indicated as the lesion is not suggestive of infection. Reassessing the lesion in one month (choice D) could lead to a delay in diagnosis and treatment if the lesion is indeed malignant.

Correct Answer: B

Rationale: The correct answer is B: Cyanosis of the lips and nail beds. Cyanosis indicates poor oxygenation due to the bluish discoloration of the lips and nail beds, suggesting insufficient oxygen in the blood. Capillary refill time less than 2 seconds (A) is a normal finding indicating good perfusion. Warm and pink extremities (C) also suggest good circulation. Bounding peripheral pulses (D) can be associated with increased cardiac output but do not directly indicate poor oxygenation.

Correct Answer: B

Rationale: The correct answer is B: What does the pain feel like? This question is best for evaluating the quality of pain because it helps determine the characteristics and nature of the pain, such as sharp, dull, throbbing, burning, etc. Understanding the specific qualities of pain can provide valuable insights into possible causes and appropriate interventions. A: When did the pain start? This question assesses the onset of pain, not its quality. C: What makes the pain better or worse? This question evaluates exacerbating or alleviating factors, not the quality of pain. D: Where is the pain located? This question assesses the location of pain, not its quality.