An older adult client returns to the medical-surgical unit immediately following a lumbar puncture. The client appears restless, reports mild discomfort at the insertion site, and frequently reaches toward the lower back dressing. Which of the following actions should the nurse take to promote client comfort and prevent complications?
- AElevate the head of the bed to a 45-degree angle to reduce tension on the lumbar nerves and improve overall comfort.
- Assist the client to maintain a flat, side-lying or supine position while providing a calm environment.Answer
- CInstruct the unlicensed assistive personnel (UAP) to evaluate the puncture site for cerebrospinal fluid leakage while repositioning the client.
- DApply soft bilateral wrist restraints immediately to ensure the client does not remove the sterile dressing.
Answer
The nurse should assist the client to maintain a flat, side-lying or supine position while providing a calm environment.
The correct action is to keep the client in a flat position (either supine or side-lying). Following a lumbar puncture, clients must remain flat for a prescribed duration (typically 4 to 8 hours) to prevent the leakage of cerebrospinal fluid, which can cause a debilitating spinal headache. Providing a calm environment addresses the client's restlessness using a safe, non-pharmacologic approach.
Step-by-Step Solution
Key Concept
Post-Lumbar Puncture Positioning and Basic Care
Estimated Time:1m 0s