To provide comfort to a client after a lumbar puncture, what step must the nurse take?

Correct Answer: A

Rationale: The correct answer is A) Position the client flat for at least three hours or as directed by the physician. After a lumbar puncture, it is crucial to prevent complications such as postural headaches caused by a decrease in cerebrospinal fluid pressure. Keeping the client flat helps in preventing leakage of cerebrospinal fluid and reduces the risk of headaches and discomfort. Option B is incorrect because a well-lighted room and soothing music may not directly address the physiological needs of the client post-lumbar puncture. Option C is incorrect as ambulation and leg exercises can increase intracranial pressure and potentially lead to complications. Option D is incorrect as providing reading material does not address the immediate post-procedure care required after a lumbar puncture. In an educational context, it is essential for nurses to understand the importance of proper positioning after a lumbar puncture to ensure the well-being and comfort of the client. This knowledge is crucial in preventing complications and promoting optimal recovery post-procedure.

Correct Answer: A

Rationale: In the case of a client with a head injury from being thrown off a motorcycle, the most appropriate nursing intervention is option A: Assess LOC every hour or more often if needed. This is the correct answer because monitoring the client's level of consciousness is crucial in identifying any deterioration or changes in neurological status, which can indicate worsening injury or complications. Regular assessment allows for prompt intervention and prevents potential adverse outcomes. Option B, putting the code cart outside the client's room, is incorrect as it is not a priority intervention for a head injury. A code cart is usually used for medical emergencies like cardiac arrest and is not directly related to the immediate care of a head injury patient. Option C, keeping the client quiet in bed, is also incorrect. While minimizing stimuli and maintaining a calm environment is important for head injury patients, it is not the most critical intervention compared to assessing LOC. Option D, allowing one visitor at a time, is not the most appropriate intervention for a client with a head injury. While visitor restrictions may be necessary in certain cases, it is not the priority in the immediate care of a client with a head injury. In an educational context, it is essential for nursing students to understand the priority interventions for clients with head injuries to provide safe and effective care. Assessing LOC is a fundamental skill in neurological assessment and plays a crucial role in identifying changes that may require immediate intervention. This rationale highlights the importance of prioritizing interventions based on the client's condition and the potential impact on their health outcomes.

Correct Answer: A

Rationale: In understanding the differences between lesions in lower motor neurons (LMN) and upper motor neurons (UMN), it is crucial to grasp their distinct effects on neurological function. Option A, "Causes hyporeflexia and flaccidity," is the correct answer. When a lesion occurs in an LMN, it leads to hyporeflexia (reduced reflexes) and flaccidity (loss of muscle tone) due to the disruption of signals from the LMN to the muscles. This results in weakness and muscle atrophy in the affected area. Conversely, lesions in UMN, as seen in options B, C, and D, have different implications. Option B is incorrect because UMN lesions affect motor control of both upper and lower body, not just the lower body. Option C is incorrect because UMN lesions arise in structures above the spinal cord, including the brain's cortex and brainstem, not specifically above the spinal cord. Option D is incorrect as UMN lesions do not interfere with reflex arcs in the spinal cord; instead, they disrupt voluntary motor functions. Educationally, understanding the distinction between LMN and UMN lesions is vital in clinical practice. Recognizing the specific characteristics of each type of lesion aids healthcare professionals in localizing the injury and determining appropriate treatment strategies. This knowledge is fundamental for diagnosing conditions like spinal cord injuries, strokes, and neurodegenerative diseases accurately.

Correct Answer: C

Rationale: In caring for a patient experiencing an acute attack of trigeminal neuralgia, maintaining a quiet, comfortable, draft-free environment (option C) is crucial. Trigeminal neuralgia is a condition characterized by severe facial pain, often triggered by touch or movement, so a calm environment helps reduce stimuli that may exacerbate the pain. Option A, carrying out all hygiene and oral care, may worsen the pain as any touch to the face can trigger excruciating discomfort in patients with trigeminal neuralgia. Option B, using conversation to distract the patient, may not be effective as talking or movement around the patient can inadvertently increase pain. Option D, having the patient examine the mouth for residual food, is not a priority during an acute attack and may even worsen the pain due to movement. Educationally, understanding the specific care needs of patients with trigeminal neuralgia highlights the importance of creating a therapeutic environment that minimizes stimuli that can trigger pain. Nurses must prioritize pain management strategies that promote comfort and reduce sensory input to provide optimal care for patients with neurological conditions like trigeminal neuralgia.

Correct Answer: C

Rationale: The correct answer is C) Be independent in self-care and wheelchair use. For a patient with a spinal cord injury at T4, the highest-level goal of rehabilitation that is realistic is to achieve independence in self-care and wheelchair use. This is because a T4 injury typically results in paraplegia, affecting the trunk and lower extremities. While options A, B, and D involve some form of ambulation, they are not realistic goals for a patient with a T4 injury. Option A, indoor mobility in a manual wheelchair, may be achievable but does not encompass the full range of functional independence needed for daily living. Option B, ambulating with crutches and leg braces, is not feasible due to the level of the injury affecting the lower extremities. Option D, completely independent ambulation with short leg braces and canes, is also not achievable given the location of the spinal cord injury. In an educational context, understanding the level and implications of a spinal cord injury is crucial in setting appropriate rehabilitation goals. It is important for healthcare professionals to tailor rehabilitation plans to the individual's specific injury level to maximize functional independence and quality of life.