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Difficulty: HardBasic Care and Comfort

An older adult client with a history of mild dementia has just returned to the unit following a diagnostic lumbar puncture. The client is restless, repeatedly attempts to sit up in bed, and verbally reports a throbbing headache. Which of the following basic care and comfort interventions should the nurse implement? (Select all that apply.)

  1. Maintain the client in a flat, supine position for the prescribed duration of 4 to 6 hours.Answer
  2. B
    Elevate the head of the bed to 45∘45^\circ to promote cerebral venous drainage and alleviate the headache.
  3. Encourage liberal oral intake of fluids, specifically offering caffeinated beverages if not contraindicated.Answer
  4. D
    Apply soft bilateral wrist restraints to safely prevent the restless client from sitting up.
  5. E
    Instruct the unlicensed assistive personnel (UAP) to perform serial assessments of the lower extremities for motor weakness.
  6. F
    Assume the sudden restlessness is a normal exacerbation of the client's baseline dementia and withhold further neurologic evaluation.

Answer

The appropriate interventions are to maintain the client in a flat, supine position and to encourage oral fluid intake, particularly caffeinated beverages.
Following a lumbar puncture, maintaining a flat, supine position minimizes cerebrospinal fluid (CSF) leakage from the dural puncture site, which is the primary cause of a post-dural puncture headache. Additionally, encouraging fluid intake helps replenish CSF volume. Caffeine is particularly effective as a non-pharmacologic intervention because its cerebral vasoconstrictive properties help relieve the vascular component of the headache.

Step-by-Step Solution

1
Identify the primary complication the client is experiencing.
The client has a post-dural puncture headache, evidenced by the throbbing pain and the recent lumbar puncture.
Understanding the pathology of the headache (CSF leakage) dictates the appropriate comfort and positioning measures.
2
Select appropriate positioning interventions to minimize complications.
The client must remain flat and supine.
A flat position reduces gravitational pressure on the dural tear, limiting further CSF leakage.
3
Select appropriate dietary and hydration comfort measures.
Oral hydration and caffeine administration should be encouraged.
Fluids help replace lost CSF, while caffeine promotes cerebral vasoconstriction, directly counteracting the vasodilation that causes the headache.
4
Eliminate inappropriate or unsafe nursing actions.
Avoid elevating the head, inappropriately delegating assessments, applying unjustified restraints, or ignoring acute behavioral changes.
These actions represent critical safety violations in basic care, delegation, and restraint protocols.

Key Concept

Basic care and comfort following a lumbar puncture require maintaining a flat position to prevent CSF leakage, promoting hydration (often with caffeine) to manage headaches, and ensuring rigorous safety monitoring without relying on inappropriate delegation or premature restraints.
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Topics

Basic Care and Comfort

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