A nurse is caring for a client following a lumbar laminectomy. Which of the following actions should the nurse take?

Have the client wear a cervical collar for the first 12 hr.

Head of her bed elevated 30 degrees

Logroll the client every 2 hr.

Supine with her arms elevated on pillows

Answer and Explanation

The Correct Answer is C

A. A cervical collar is not necessary for a lumbar laminectomy. A cervical collar is used for neck surgeries or spinal cord injuries involving the cervical spine, not for lumbar procedures.

B. The head of the bed elevated 30 degrees may be appropriate for certain conditions, but after a lumbar laminectomy, it is typically recommended to keep the head of the bed flat or slightly elevated to reduce pressure on the spine.

C. Logrolling the client every 2 hr is the correct action. After a lumbar laminectomy, the nurse should use the logroll technique to turn the patient to prevent strain on the spine and promote proper healing.

D. Supine with her arms elevated on pillows is not the best position. While elevation of the arms may be helpful for comfort, the focus should be on protecting the lumbar spine and ensuring proper positioning to prevent strain.

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Correct Answer is A

Explanation

A. Attempt to determine what the client was looking for is the best response. In Alzheimer's disease, clients may exhibit wandering behavior and confusion, often seeking something familiar or trying to meet an unmet need. Understanding what the client was looking for can help address their needs and prevent further agitation.

B. Reprimanding the client for invading the other client's privacy is not appropriate. Clients with Alzheimer's disease may not be aware of the concept of privacy or the impact of their actions. Reprimanding can cause distress and confusion.

C. Explaining the client's Alzheimer's diagnosis to the frightened client may help provide understanding, but it does not address the immediate concern of calming the frightened client. The focus should be on managing the behavior in the moment.

D. Asking the client to apologize for his behavior is not appropriate, as the client may not have the cognitive ability to understand or remember the need to apologize. This could cause frustration and confusion.

A. Unstable blood pressure B. Diabetes insipidus C. Diabetes mellitus D. Altered respiratory rate

Correct Answer is B

Explanation

A. Unstable blood pressure can occur with damage to the hypothalamus or pituitary, but it is more commonly associated with other neurological conditions. While blood pressure may fluctuate, it is not the most direct result of pituitary or hypothalamic damage.

B. Diabetes insipidus is the correct answer. The pituitary gland secretes antidiuretic hormone (ADH), which helps regulate water balance. Damage to the pituitary or hypothalamus can lead to a deficiency of ADH, causing diabetes insipidus, which is characterized by excessive thirst and urination.

C. Diabetes mellitus is a condition related to insulin production and blood sugar regulation, typically caused by pancreatic issues, not damage to the pituitary or hypothalamus.

D. Altered respiratory rate can occur with brain injury, but it is more commonly associated with damage to the brainstem rather than the hypothalamus or pituitary.

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A nurse is caring for a client following a lumbar laminectomy. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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