Examkin

Question

Difficulty: EasyBasic Care and Comfort

An 80-year-old client has just returned to the medical-surgical unit following a diagnostic lumbar puncture. The client is currently alert and oriented. Which of the following actions is the most appropriate for the nurse to implement in the client's immediate care plan?

  1. Maintain the client in a flat, supine position for the prescribed duration.Answer
  2. B
    Elevate the head of the bed to a semi-Fowler's position to promote chest expansion.
  3. C
    Delegate the initial post-procedure site assessment to unlicensed assistive personnel (UAP).
  4. D
    Reassure the family that any sudden onset of mild confusion is a normal age-related change.

Answer

Maintain the client in a flat, supine position for the prescribed duration.
Following a lumbar puncture, the client should remain in a flat, supine position for several hours as prescribed by the healthcare provider. This specific basic care intervention prevents cerebrospinal fluid from leaking out of the dural puncture site, which is the primary pathophysiological cause of a post-lumbar puncture headache.

Step-by-Step Solution

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different diagnostic procedures require specific post-operative care and positioning to ensure basic care and comfort.
2
Determine the standard of care for a post-lumbar puncture client.
The standard is to keep the client flat to prevent cerebrospinal fluid (CSF) leakage.
A decrease in CSF volume can cause a severe post-dural puncture headache, significantly impacting the client's comfort.
3
Evaluate the nursing actions against safe practice principles.
Keeping the client flat is safe and indicated. Elevating the head is contraindicated. Delegating an initial assessment is unsafe. Ignoring sudden confusion in older adults is unsafe.
Ensures evidence-based, safe, and effective nursing care.

Key Concept

Post-lumbar puncture care and positioning
Rate this question

Topics

Basic Care and Comfort

More questions from this topic