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 B

Explanation

A. Limiting the client's physical activity is not recommended for clients with Parkinson's disease. Physical activity, including exercises to improve strength, balance, and flexibility, is essential to manage symptoms and maintain mobility.

B. Providing the client a cane is appropriate. A cane can help with balance and stability, especially as the client experiences motor symptoms such as rigidity and bradykinesia. It can reduce the risk of falls.

C. Offering the client 3 large meals a day is not ideal. Smaller, more frequent meals are recommended for clients with Parkinson's disease, as they may experience difficulty swallowing, digestion issues, or a reduced appetite.

D. Speaking loudly to the client is not necessary unless the client has difficulty hearing. It is more important to speak clearly and at a normal volume, as clients with Parkinson's disease may have issues with speech (e.g., soft or slurred speech).

A. Palpebral angle rigid, right and left angles B. Patient's eyes round, regular, lively, active C. Pupils equal, round, and reactive to light and accommodation D. Pupils equilateral, regular, round, little accommodation

Correct Answer is C

Explanation

A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.

B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.

C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.

D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching to the family of a client who has Parkinson's disease. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Correct Answer is C

Explanation

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