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 A
Explanation
A. Providing a dark, quiet environment is an appropriate intervention for a client with a migraine headache. Migraines are often aggravated by bright lights and loud noises, so creating a calm, low-stimulation environment can help alleviate symptoms.
B. While caffeine can be a trigger for some individuals with migraines, it is not necessary to eliminate all caffeine. In fact, caffeine is sometimes included in medications for migraines to enhance their effectiveness.
C. Cognitive impairment is not a typical concern for migraines unless the headache is severe or prolonged. Monitoring for cognitive impairment would not be the primary action in this scenario.
D. Opioids are not recommended for the treatment of migraines due to their potential for abuse and side effects. NSAIDs, triptans, and other specific migraine treatments are preferred.
Correct Answer is D
Explanation
A. Dysphasia is a general term for difficulty with speech and language, which can involve problems with speaking, understanding, reading, or writing. It is not specific to the patient's response of raising an arm instead of sticking out the tongue.
B. Dysarthria refers to difficulty with the physical act of speaking due to weakness or incoordination of the muscles involved in speech. It does not involve comprehension or understanding of language.
C. Expressive aphasia refers to difficulty expressing thoughts verbally or in writing, but the patient typically understands language. This does not match the patient's response to the nurse's command.
D. Receptive aphasia is characterized by difficulty understanding spoken or written language. The patient may not comprehend the nurse's instructions, leading to inappropriate responses, such as raising an arm instead of sticking out the tongue.
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