18. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note:
A. Vertigo, tinnitus, and hearing loss.
B. Vertigo, vomiting, and nystagmus
C. Vertigo, pain, and hearing impairment.
D. Vertigo, blurred vision, and fever.
Answer: A. Vertigo, tinnitus, and hearing loss.
Ménière's disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Ménière's disease rarely causes pain, blurred vision, or fever.
Answer: C. Obesity
Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age.
12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing
blood pressure.
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
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Lab test lumbar puncture
Terms in this set [8]
Lumbar Puncture
introduction of a specialized needle into the spine in the lumbar region for diagnostic or therapeutic purpose, such as to obtain cerebrospinal fluid for testing;also called spinal tap
Nursing responsibility for LP
Explain procedure; obtain written consent; have patient use restroom; assist doctor with procedure if asked.
Post LP nursing responsibility.
apply pressure and a dressing to the puncture site; place patient in the prone position with a pillow under the abdomen; encourage fluids; keep patient in reclining position for up to 12 hours or as ordered; assess patient for numbness or tingling, pain at injection site, drainage of blood or CSF; ability to void.
Why is an LP performed?
To obtain CSF for examination, to relieve pressure, or to introduce dye or medication.
How is the patient normally placed for an LP?
On their side with the knee and head flexed.
Where is the needle introduced?
L4, L5-S1 interspace
Most common side effects of an LP?
Headache, pain at injection site
What type of pain medication is ordered for a patient after an LP?
non-opioids
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