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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Place suction equipment at the client's bedside: Impairment of cranial nerves IX and X can lead to difficulty swallowing and impaired gag reflex, increasing the risk of aspiration and airway obstruction. Therefore, having suction equipment readily available is essential to maintain a patent airway and manage secretions effectively.

B. Provide range-of-motion exercises to the client's neck and shoulders: While range-of-motion exercises may be beneficial for preventing muscle stiffness and contractures, they are not directly related to the client's risk of airway compromise or aspiration.

C. Apply an eye patch to the client's right eye: Acoustic neuroma typically affects cranial nerves VII and VIII, leading to symptoms such as hearing loss and facial weakness. Applying an eye patch to the client's right eye is not necessary for cranial nerve IX and X impairment unless there are specific ocular symptoms.

D. Avoid the use of warm water to wash the client's face: Warm water may be used to wash the client's face safely and is not contraindicated specifically for a client with impairment of cranial nerves IX and X. However, precautions should be taken to ensure that water does not enter the airway if the client has difficulty swallowing or impaired gag reflex.

A. Place the client with the head reclined back to facilitate swallowing. B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Encourage brief exercise before meals to promote appetite.

Correct Answer is C

Explanation

A. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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