The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain with opposite side affected extremities. The nurse notices that the patient does not easily reach items placed at the bedside. In which area does the nurse place items for easy access?

Left Side

Right Side

Directly in front

Where the patient wants

Answer and Explanation

The Correct Answer is B

A. Placing items on the left side would not be appropriate for a patient with a right-sided weakness (hemiparesis) due to a left-sided ischemic stroke. This would make it harder for the patient to reach the items.

B. Placing items on the right side of the patient is the best option. Since the patient has weakness on the right side, they would have better access to items placed on the unaffected side (left side of the body).

C. Placing items directly in front of the patient could be helpful, but it depends on the severity of the stroke and the patient's ability to move and reach forward. It may not be as effective if the patient has limited mobility.

D. Placing items where the patient wants is a good practice, but the nurse should ensure the placement is practical for the patient's abilities. It is more important to place items on the right side to optimize access.

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Correct Answer is D

Explanation

A. The client should not sit upright in a chair for prolonged periods (such as 4 hours at a time) immediately following spinal fusion, as this could place excessive strain on the surgical site. The client should be assisted to sit upright for short periods and be repositioned regularly.

B. Clear drainage on the spinal dressing could indicate cerebrospinal fluid leakage, which is a concern following spinal surgery. The nurse should expect minimal to no drainage, and if clear fluid is observed, it should be reported immediately.

C. Elevating the client's legs when lying on his side may not be necessary unless specifically ordered by the healthcare provider. In general, the client should maintain proper body alignment and avoid any positions that strain the surgical site.

D. Log rolling is a critical intervention for spinal fusion patients to prevent twisting of the spine. The nurse should assist the client in log rolling every 2 hours to maintain spinal alignment and prevent injury to the surgical site.

A. Have the client wear a cervical collar for the first 12 hr. B. Head of her bed elevated 30 degrees C. Logroll the client every 2 hr. D. Supine with her arms elevated on pillows

Correct Answer is C

Explanation

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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The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain with opposite side affected extremities. The nurse notices that the patient does not easily reach items placed at the bedside. In which area does the nurse place items for easy access?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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