— 降低風險 · MEDIUM · SATA —
病人接受腰椎穿刺（Lumbar Puncture）返回病房，下列哪些護理措施是適當的？（選所有適合的）
Which of the following nursing interventions are appropriate for a client returning from a lumbar puncture? (Select all that apply.)
- AEncourage increased fluid intake✓ 正解鼓勵增加水分攝取
- BMaintain the client in a flat supine position✓ 正解維持病人仰臥平躺姿勢
- CMonitor for headaches✓ 正解監測是否有頭痛
- DPerform neurological checks every 4 hours✓ 正解每 4 小時進行神經學評估
- EApply a warm compress to the puncture site在穿刺部位敷熱敷
— Explanation · 中文詳解 —
腰椎穿刺後應平躺 4-12 小時（視醫師醫囑）以預防腦脊髓液滲漏導致的「穿刺後頭痛」。增加水分攝取有助於腦脊髓液再生。持續監測神經學狀態以偵測併發症。熱敷（E）不適當，因為可能導致局部充血出血，應維持傷口乾燥。
After a lumbar puncture, the nurse should encourage increased fluid intake to help replenish cerebrospinal fluid and maintain the client in a flat supine position to prevent CSF leakage and subsequent headaches. Monitoring for headaches and performing regular neurological checks are critical to detect complications early, while warm compresses are avoided to prevent local congestion or bleeding.
✦ 台美臨床差異
美國護理對於平躺時間的規定可能依臨床路徑（Clinical Path）縮短至 1-2 小時；台灣臨床實務多仍採取 6-8 小時平躺。