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Question

Difficulty: MediumBasic Care and Comfort

An adult client who underwent a diagnostic lumbar puncture four hours ago is now complaining of a severe, throbbing headache that worsens upon sitting. When planning interventions to promote comfort and safety, which action should the nurse implement?

  1. A
    Raise the head of the bed to a semi-Fowler's position to reduce the intracranial pressure causing the pain.
  2. Keep the client in a flat, supine position while offering frequent oral fluids.Answer
  3. C
    Delegate the task of assessing the client's pain characteristics and puncture site to the assistive personnel.
  4. D
    Reassure the client that there is nothing to worry about since headaches are a typical outcome of this test.

Answer

Keep the client in a flat, supine position while offering frequent oral fluids.
Post-lumbar puncture headaches are frequently caused by the leakage of cerebrospinal fluid from the dural puncture site. Keeping the client in a flat position minimizes this leakage and decreases the gravitational pull on the pain-sensitive meninges. Furthermore, encouraging oral fluid intake helps to actively replenish the lost cerebrospinal fluid volume, directly addressing the root cause of the client's discomfort.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a severe, throbbing headache that worsens when sitting up, four hours after a lumbar puncture.
Identifying the timing and characteristics of the symptom points to a post-dural puncture headache caused by cerebrospinal fluid leakage.
2
Determine the appropriate physiological intervention for a post-lumbar puncture headache.
The standard intervention is keeping the client flat and increasing hydration.
Lying flat reduces tension on the meninges by preventing gravity-induced downward displacement of the brain, while hydration helps restore cerebrospinal fluid volume.
3
Evaluate the other proposed nursing actions for safety and efficacy.
Elevating the head worsens the pain, delegating assessment is unsafe, and false reassurance is non-therapeutic.
Nursing actions must align with safety guidelines, proper delegation boundaries, and therapeutic communication standards.

Key Concept

Post-Lumbar Puncture Comfort and Positioning
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Topics

Basic Care and Comfort

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