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Difficulty: MediumBasic Care and Comfort

A client is admitted to the medical-surgical unit immediately following a lumbar puncture. The client reports a mild, dull headache. Which of the following nursing actions is most appropriate?

  1. A
    Elevate the head of the bed to at least 45 degrees to decrease intracranial pressure and relieve the headache.
  2. B
    Instruct the unlicensed assistive personnel (UAP) to evaluate the lumbar dressing for signs of bleeding or cerebrospinal fluid leakage.
  3. C
    Explain to the client's family that sudden confusion and severe lethargy are expected age-related responses to the procedure.
  4. Maintain the client in a flat, supine position for the prescribed duration and encourage oral fluid intake.Answer

Answer

Maintain the client in a flat, supine position for the prescribed duration and encourage oral fluid intake.
Following a lumbar puncture, clients are at risk for developing a spinal headache due to the leakage of cerebrospinal fluid from the puncture site. Maintaining the client in a flat, supine position for several hours (usually 4 to 8 hours depending on facility policy) minimizes gravity-assisted leakage. Additionally, encouraging oral fluid intake, if not contraindicated, helps replenish the cerebrospinal fluid volume, thereby resolving the headache and promoting client comfort.

Step-by-Step Solution

1
Identify the client's recent procedure and current symptoms.
The client had a lumbar puncture and is experiencing a mild headache, a common complication known as a spinal headache.
Understanding the clinical context is essential to determine the correct nursing intervention.
2
Determine the physiological cause of a post-lumbar puncture headache.
The headache is caused by the leakage of cerebrospinal fluid through the dural puncture, which decreases fluid volume and intracranial pressure.
Identifying the cause guides the selection of interventions to restore fluid volume and prevent further leakage.
3
Select the intervention that addresses the physiological cause.
Keeping the client flat minimizes gravity-induced cerebrospinal fluid leakage, and providing oral fluids helps rapidly replenish the lost fluid.
These combined actions effectively promote comfort and resolve the headache.

Key Concept

Post-Lumbar Puncture Positioning and Hydration
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Topics

Basic Care and Comfort

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