Page 2592 - Saunders Comprehensive Review For NCLEX-RN

882. Answer: 4

Rationale: A client undergoing lumbar puncture is positioned lying on the side,
with the legs pulled up to the abdomen and the head bent down onto the chest. This
position helps open the spaces between the vertebrae and allows for easier needle
insertion by the primary health care provider. The nurse remains with the client
during the procedure to help the client maintain this position. The other options
identify incorrect positions for this procedure.
Test-Taking Strategy: Focus on the subject, lumbar puncture. Recalling that a
lumbar puncture is the introduction of a needle into the subarachnoid space will
direct you to the correct option. It is reasonable that the position of the client must
facilitate this, and the correct option is the only position that flexes the vertebrae and
widens the spaces between them.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Diagnostic Tests
Health Problem: N/A
Priority Concepts: Intracranial Regulation; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 855.

883. Answer: 1, 2, 5

Rationale: Maintaining effective and open communication among family
members affected by death and grief is of the greatest importance. Option 1
describes encouraging discussion of feelings and is likely to enhance
communication. Option 2 is also an effective intervention because spiritual practices
give meaning to life and have an impact on how people react to crisis. Option 5 is
also an effective technique because the client and family need to know that someone
will be there who is supportive and nonjudgmental. The remaining options describe
the nurse removing autonomy and decision making from the client and family, who
are already experiencing feelings of loss of control in that they cannot change the
process of dying. These are ineffective interventions that could impair
communication further.
Test-Taking Strategy: Focus on the subject, the interventions that will facilitate
effective communication. Use of therapeutic communication techniques and
focusing on the subject will assist you in answering correctly. The incorrect options
remove control from the client and family.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Developmental Stages: End-of-Life Care
Health Problem: Mental Health: Grief/Loss
Priority Concepts: Caregiving; Family Dynamics
Reference: Potter et al. (2017), pp. 763-764.

884. Answer: 3

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