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.
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Related Questions
Correct Answer is ["B","C"]
Explanation
A. Turn the client to the side is the correct action to prevent aspiration, but restraining the client is not appropriate. Restraint can cause injury and should never be used during a seizure. The client should be allowed to move freely during the seizure, and positioning them on their side helps maintain an open airway and prevent aspiration.
B. Time the duration of the seizure is essential for monitoring the length of the seizure. This helps the nurse determine if the seizure is prolonged or if medical intervention is necessary.
C. Administer supplemental oxygen to the client is appropriate if the client is experiencing apnea or breathing difficulties during the seizure. The nurse should ensure the oxygen equipment is ready and functioning to provide supplemental oxygen if needed.
D. Placing a tongue depressor in the client's mouth is not recommended during a seizure. This can cause injury to the client’s mouth, teeth, or airway and does not prevent biting the tongue. Instead, the nurse should focus on protecting the client's airway and preventing aspiration.
Correct Answer is A
Explanation
A. The postictal phase refers to the period immediately following a seizure when the client is often drowsy, confused, or difficult to arouse. This phase can last for several minutes to hours, depending on the individual.
B. Absence seizures are brief, generalized seizures characterized by staring and loss of awareness, often without a postictal phase.
C. The aura phase refers to the sensory warning or symptoms that precede a seizure, not the post-seizure state.
D. Automatisms are involuntary, repetitive movements (such as lip smacking or hand wringing) that can occur during a seizure, but they do not describe the postictal state.
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