Examkin

Soru

Zorluk: KolayReduction of Risk Potential

A nurse is assuming care for a client who underwent a lumbar puncture 30 minutes ago. Which of the following positions should the nurse maintain to minimize the client's risk of developing a post-procedure complication?

  1. Supine with the head of the bed flatCevap
  2. B
    High-Fowler's with the knees slightly flexed
  3. C
    Left lateral with the chin tucked to the chest
  4. D
    Reverse Trendelenburg with the head elevated

Cevap

Supine with the head of the bed flat
The correct answer is to keep the client supine with the head of the bed flat. Following a lumbar puncture, a small hole remains in the dura mater. Remaining flat minimizes hydrostatic pressure on this site, reducing the risk of cerebrospinal fluid (CSF) leakage and the subsequent development of a severe spinal headache.

Adım Adım Çözüm

1
Identify the procedure performed and its most common complications.
The client had a lumbar puncture, which carries a high risk of cerebrospinal fluid (CSF) leakage leading to a debilitating spinal headache.
Understanding the procedure's specific risks dictates the appropriate preventive nursing interventions.
2
Determine the correct nursing intervention to prevent this specific complication.
Keeping the client completely flat distributes CSF pressure evenly and minimizes leakage from the dural puncture site.
Gravity increases pressure on the puncture site if the head is elevated, exacerbating the leak.
3
Select the option that matches this positioning requirement.
The supine position with the head of the bed flat is the correct choice.
This directly addresses the physiological risk identified and ensures client safety.

Anahtar Kavram

Post-lumbar puncture positioning to prevent spinal headache
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Konular

Reduction of Risk Potential

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