Examkin

Question

Difficulty: MediumBasic Care and Comfort

A client with a history of early-stage Alzheimer's disease is transferred to the medical unit immediately following a diagnostic lumbar puncture. The client appears highly restless, repeatedly attempts to sit up in bed, and reports generalized back discomfort. Which nursing intervention should be prioritized to promote client safety and comfort?

  1. A
    Assign the nursing assistant to perform neurological checks and inspect the puncture site every fifteen minutes.
  2. B
    Raise the head of the bed to a semi-Fowler's angle to help soothe the client and relieve back pressure.
  3. Maintain the client in a flat, supine position while minimizing environmental noise and providing a warm blanket.Answer
  4. D
    Initiate physical restraint application to ensure the client remains flat and does not dislodge the sterile dressing.

Answer

Maintain the client in a flat, supine position while minimizing environmental noise and providing a warm blanket.
Following a lumbar puncture, the standard of care requires the client to remain in a flat, supine position for several hours to minimize the risk of cerebrospinal fluid leakage and a subsequent spinal headache. Providing a warm blanket and reducing environmental noise are appropriate non-pharmacological comfort measures that can help decrease the client's restlessness safely without resorting to restraints or contraindicated positioning.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent procedure.
The client recently underwent a lumbar puncture and is experiencing restlessness with back discomfort.
Identifying the specific procedure dictates the required post-operative positioning and helps anticipate potential complications.
2
Evaluate the proposed positioning and comfort interventions.
Supine positioning is required to prevent cerebrospinal fluid leakage; elevating the head of the bed increases the risk of a spinal headache and is contraindicated.
Post-procedure comfort measures must not compromise the physiological safety of the puncture site.
3
Assess the appropriateness of delegation and safety enforcement.
Assessments cannot be delegated to unlicensed assistive personnel, and restraints are inappropriate as a first-line intervention for restlessness.
Nursing actions must strictly adhere to the scope of practice and established least-restrictive restraint protocols.

Key Concept

Post-Lumbar Puncture Basic Care and Safety
Rate this question

Topics

Basic Care and Comfort

More questions from this topic