# A client reports a severe headache that worsens when sitting up after a lumbar puncture. Which action should the nurse anticipate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397281&lang=en  
> language: en  
> subject: Changes in Vital Signs  
> category: ROR

## Question

A client reports a severe headache that worsens when sitting up after a lumbar puncture. Which action should the nurse anticipate?

## Option

1. Encourage vigorous ambulation.
2. Restrict all oral and IV fluids.
3. Place the client in high Fowler position.
4. Maintain prescribed positioning and notify the provider. **✔ Correct answer**

**Correct answer: 4**

## 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.

## In-depth explanation

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 scenario

Clinical Practice Guide
For Post lumbar puncture headache, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **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.

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