The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response?

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11ecbb05_ca30_824f_b433_051bd43d4c91_MD0009_00 A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required. (Option A) Fluids are encouraged to help replace the cerebrospinal fluid. (Option C) The client should lie flat for at least 4 hours. The prone or supine position is recommended to help prevent a headache. (Option D) Up to 5%-30% of clients have the common complication of headache. It is thought to be a result of leakage of fluid through the dural puncture site. The symptom is treated and is normally self-limiting. Educational objective: After a lumbar puncture, cerebrospinal fluid leakage from the puncture site requires health care provider notification for a blood patch. A headache after the procedure is an expected finding. The client should lie flat and increase fluid intake afterwards.

The Nurse Is Caring for a Client After a Lumbar