A client reports a severe headache that worsens when sitting up after a lumbar puncture. Which action should the nurse anticipate?
1Encourage ambulation every 2 hours to prevent stiffness.
2Restrict oral fluids to 1 L per day and monitor IV fluid rate.
3Maintain prescribed positioning and notify the provider.✓ Correct answer
4Position the client with the head of bed elevated fully upright.
Explanation
A positional headache after lumbar puncture can suggest cerebrospinal fluid leak. The nurse should follow prescribed positioning, support hydration if ordered, and notify the provider for further management. Upright positioning and vigorous ambulation can worsen symptoms.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Post lumbar puncture headache.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Post lumbar puncture headache, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Lumbar Puncture — A procedure to access cerebrospinal fluid from the spinal canal.
Cerebrospinal Fluid Leak — Loss of CSF that can cause a positional headache.
Post-Dural Puncture Headache — A headache that may occur after dural puncture and often worsens upright.