Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?

Lie flat.

Lie on left side.

Stay in semi-Fowler position.

Ambulate in the room with assistance.

Answer and Explanation

The Correct Answer is A

A. Lie flat:

This option involves instructing the patient to lie flat on their back without elevating their head. Lying flat helps to maintain consistent pressure in the spinal canal, reducing the likelihood of CSF leakage from the puncture site. This position is commonly recommended after a lumbar puncture to prevent or minimize the occurrence of post-lumbar puncture headaches (PLPH).

B. Lie on left side:

This option involves instructing the patient to lie on their left side. While lying on the left side may provide some relief by reducing pressure on the lumbar puncture site, it is not typically recommended immediately after the procedure to prevent PLPH. Lying flat is generally preferred to minimize changes in CSF pressure and reduce the risk of headache.

C. Stay in semi-Fowler position:

The semi-Fowler position involves elevating the head of the bed at a 30-45 degree angle. This position is not typically recommended immediately after a lumbar puncture because it may increase CSF leakage and pressure changes, potentially exacerbating the risk of developing a headache.

D. Ambulate in the room with assistance:

Ambulating shortly after a lumbar puncture is not typically recommended as it may increase the risk of developing a headache. Movement and changes in posture can exacerbate CSF leakage and pressure changes at the puncture site, leading to the development of post-lumbar puncture headaches.

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Correct Answer is A

Explanation

A. The client should maintain systolic BP between 120 and 129 mm Hg.

This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.

B. The client should maintain systolic BP between 130 and 135 mm Hg.

This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.

C. The client should maintain systolic BP between 136 and 140 mm Hg.

This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

D. The client should maintain systolic BP between 141 and 145 mm Hg.

This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

A. Polyuria B. Battle's sign C. Nuchal rigidity D. Lethargy

Correct Answer is D

Explanation

A. Polyuria:

Polyuria, or increased urine output, is not typically associated with increased intracranial pressure. It may occur due to other factors such as diabetes insipidus or fluid administration.

B. Battle's sign:

Battle's sign refers to bruising behind the ear and is often associated with basilar skull fractures. While it can indicate a head injury, it is not a direct manifestation of increased intracranial pressure.

C. Nuchal rigidity:

Nuchal rigidity, stiffness of the neck muscles, is commonly associated with meningitis rather than increased intracranial pressure. It is a sign of meningeal irritation and inflammation rather than direct pressure within the skull.

D. Lethargy:

This is the correct answer. Lethargy, or excessive drowsiness or fatigue, can be an early manifestation of increased intracranial pressure. As pressure increases within the skull, it can lead to alterations in consciousness ranging from lethargy to coma. Monitoring the client for changes in level of consciousness, including lethargy, is important for early detection of increased intracranial pressure.

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Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?

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