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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Educating the client on anticonvulsant medications is important, but it is not the priority during an active seizure. Education should be provided after the seizure has ended.
B. Monitoring vital signs is important but should not be the immediate priority during a seizure. The nurse should focus on airway management first.
C. Restraining the client is contraindicated during a seizure. Restraining can cause injury to both the client and the nurse. The focus should be on protecting the client from harm.
D. The prevention of occlusion of the airway or aspiration is the priority. During a tonic-clonic seizure, there is a risk of the client choking, biting their tongue, or having difficulty breathing. The nurse should ensure the airway is open, prevent aspiration, and protect the client from injury during the seizure.
Correct Answer is A
Explanation
A. A concussion is considered a mild traumatic brain injury (TBI) that typically results in a temporary loss of brain function. It is often caused by a blow to the head and may result in confusion, dizziness, and loss of consciousness. However, if concussions occur repeatedly, they can lead to long-term cognitive impairment and other serious conditions like chronic traumatic encephalopathy (CTE).
B. A brainstem contusion is a more severe injury that affects the brainstem, which controls vital functions like breathing and heart rate. It is not classified as a mild injury.
C. A subdural hematoma is a collection of blood between the brain and its outermost covering. It is a serious condition that can result from a traumatic brain injury and is not considered mild.
D. An epidural hematoma is a collection of blood between the skull and the dura mater. It is often caused by a traumatic head injury and is considered a medical emergency, not a mild injury.
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