Examkin

Soru

Zorluk: KolayBasic Care and Comfort

A client arrives at the medical unit after undergoing a diagnostic lumbar puncture. Which positioning instruction is the most appropriate for the nurse to provide?

  1. Remain completely flat in bed for the duration prescribed by the provider.Cevap
  2. B
    Elevate the head of the bed to a 45-degree angle while resting.
  3. C
    Maintain a side-lying fetal position with the knees pulled to the chest.
  4. D
    Sit upright in a bedside chair to promote drainage of cerebrospinal fluid.

Cevap

The client should remain completely flat in bed for the duration prescribed by the provider.
Following a lumbar puncture, the standard of care requires the client to remain flat (supine) in bed for a specified duration, typically 1 to 8 hours depending on provider orders. This flat position minimizes hydrostatic pressure at the dural puncture site, significantly reducing the risk of cerebrospinal fluid (CSF) leakage and the development of a post-dural puncture headache.

Adım Adım Çözüm

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different procedures require specific post-operative or post-procedure positioning to prevent complications.
2
Determine the primary risk following a lumbar puncture.
The main risk is leakage of cerebrospinal fluid (CSF) from the dural puncture site, which causes a severe spinal headache.
Understanding the complication guides the appropriate nursing intervention.
3
Select the position that minimizes this risk.
Lying completely flat reduces pressure on the dural tear, preventing CSF leakage.
Gravity exacerbates the pressure on the puncture site when the head is elevated.

Anahtar Kavram

Post-Lumbar Puncture Positioning
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Konular

Basic Care and Comfort

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