Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A 72-year-old client who underwent a diagnostic lumbar puncture two hours ago rings the call bell. The client reports a severe, throbbing headache that significantly worsens when attempting to sit up, and the client appears mildly disoriented to time. What is the most appropriate initial nursing action to promote comfort and safety?

  1. Maintain the client in a strictly flat, supine position and encourage increased oral hydration.Cevap
  2. B
    Elevate the head of the bed to a semi-Fowler's position to facilitate cerebral venous drainage.
  3. C
    Direct the unlicensed assistive personnel to closely monitor and document the client's neurological status and pain severity.
  4. D
    Document the mild disorientation as an expected cognitive change of the aging process and dim the room lights.

Cevap

The most appropriate action is to maintain the client in a strictly flat, supine position and encourage increased oral hydration.
The correct action directly addresses the etiology of a post-dural puncture headache. Following a lumbar puncture, leakage of cerebrospinal fluid (CSF) can occur, leading to decreased intracranial volume. When the client sits upright, the brain sags, pulling on the meninges and causing severe pain. Maintaining a flat, supine position removes the gravitational pull, providing immediate comfort. Additionally, encouraging oral fluids (if not contraindicated) helps accelerate the body's natural production of CSF to replace what was lost.

Adım Adım Çözüm

1
Analyze the client's symptoms and recent procedure.
The client has a severe headache worsening upon sitting up following a lumbar puncture.
This presentation is the classic hallmark of a post-dural puncture headache (spinal headache) caused by the leakage of cerebrospinal fluid (CSF).
2
Identify the underlying physiological mechanism.
Decreased CSF volume causes the brain to sag downward when the client sits upright, placing traction on pain-sensitive meninges.
Understanding that gravity exacerbates the traction dictates the required positioning intervention.
3
Select the appropriate nursing intervention for basic care and comfort.
Position the client completely flat (supine) to eliminate the gravitational pull and provide fluids to help replace the lost CSF.
This conservative management approach directly addresses the physical cause of the discomfort while maintaining client safety.

Anahtar Kavram

Post-procedure Positioning and Comfort Interventions for Lumbar Puncture
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru