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Question

Difficulty: EasyReduction of Risk Potential

Following a diagnostic lumbar puncture, a client is transferred back to the clinical unit. Which action should the nurse implement to reduce the client's risk of developing a post-dural puncture headache?

  1. Maintain the client in a flat, supine position for several hours.Answer
  2. B
    Elevate the head of the client's bed to a semi-Fowler's position.
  3. C
    Delegate the immediate post-procedure assessment to unlicensed assistive personnel.
  4. D
    Encourage the client to ambulate around the room to promote circulation.

Answer

The nurse should maintain the client in a flat, supine position for several hours.
Maintaining a flat, supine position for several hours minimizes the hydrostatic pressure of cerebrospinal fluid at the lumbar puncture site. This prevents CSF leakage, which is the underlying cause of a post-dural puncture headache.

Step-by-Step Solution

1
Identify the primary complication associated with a lumbar puncture.
The most common complication is a post-dural puncture headache, caused by the leakage of cerebrospinal fluid (CSF) from the puncture site.
Understanding the pathophysiology of the complication dictates the appropriate nursing intervention.
2
Determine the optimal intervention to prevent this complication.
Keeping the client flat and supine minimizes hydrostatic pressure on the dura mater.
Reduced pressure allows the puncture site to heal and prevents further CSF leakage.

Key Concept

Post-Lumbar Puncture Positioning
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Topics

Reduction of Risk Potential

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