A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?
Administer naproxen.
Elevate the head of the bed to 30°.
Check BP and call for a blood patch.
Darken the client's room and close the door.
The Correct Answer is C
A. Administer naproxen: While pain management is important, naproxen may not effectively resolve the headache associated with post-lumbar puncture headache (PLPH), which is often caused by cerebrospinal fluid leakage.
B. Elevate the head of the bed to 30°: While elevating the head of the bed may provide some relief, it is not typically sufficient to resolve PLPH, which often requires more definitive interventions.
C. Check BP and call for a blood patch: PLPH is commonly treated with a blood patch, which involves injecting the patient's own blood into the epidural space to seal the puncture site and restore normal cerebrospinal fluid pressure. Checking blood pressure is important to assess for hypotension, and calling for a blood patch is the most appropriate action to address the underlying cause of the headache.
D. Darken the client's room and close the door: While creating a quiet and dim environment may help alleviate symptoms of headache, it does not address the underlying cause of PLPH and is not the most appropriate intervention in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.
B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.
C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.
D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.
Correct Answer is D
Explanation
A. Therapeutic effects of medications may not be seen for 2-3 weeks: While it is important for the client to understand the timeline for therapeutic effects, ensuring medication adherence, especially during the initial period when therapeutic effects are not yet apparent, is of higher priority.
B. Physical dependency may result from extended use of medications: While the potential for physical dependency is an important consideration, ensuring medication compliance and adherence to the prescribed regimen, particularly in the context of managing seizures, takes precedence.
C. Urine may turn pink to brown but is not harmful: While this information may be included in the education plan to address potential side effects of antiepileptic medications, it is not the highest priority compared to ensuring the client understands the importance of taking medication regularly.
D. Take medication even if there is no seizure activity: Ensuring consistent medication adherence is crucial in managing seizure disorders to maintain therapeutic blood levels of antiepileptic medications and reduce the risk of breakthrough seizures. Missing doses can increase the risk of seizure recurrence.
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