When caring for a patient after lumbar spinal surgery, the nurse would immediately report which finding to the healthcare provider?
The patient has loss of sensation to the perineum, buttocks, inner thighs, and back of the legs.
The patient is nauseated and has not voided in 4 hours.
The patient reports mild low back pain.
The patient has a single episode of emesis.
The Correct Answer is A
Choice A rationale
Loss of sensation to the perineum, buttocks, inner thighs, and back of the legs may indicate cauda equina syndrome, a surgical emergency. This condition involves compression of the spinal nerve roots and can lead to permanent neurological damage if not promptly addressed. Immediate medical intervention is critical.
Choice B rationale
Nausea and delayed voiding postoperatively are common, potentially due to anesthesia effects or limited mobility. While these findings warrant monitoring, they do not typically indicate an urgent issue unless prolonged or associated with other complications.
Choice C rationale
Mild low back pain is expected after lumbar spinal surgery due to manipulation of spinal structures. Pain management with prescribed analgesics and gradual mobilization is part of the standard postoperative care plan, and it does not usually necessitate immediate reporting.
Choice D rationale
A single episode of emesis can result from anesthesia effects or medication. Unless accompanied by persistent vomiting, signs of aspiration, or electrolyte imbalances, isolated emesis is not typically urgent and should be managed with antiemetics if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A rationale
Assessing the range of motion of a severely injured leg is not appropriate during initial evaluation. Movement can worsen the injury or disrupt stabilizing measures such as splints or dressings.
Choice B rationale
Asking the patient to stand or bear weight risks further injury and is contraindicated in cases of visible deformity or massive bleeding.
Choice C rationale
Evaluating skin color helps identify potential ischemia, vascular compromise, or inadequate perfusion. Pallor or cyanosis can indicate significant circulation issues needing urgent care.
Choice D rationale
Paresthesia (tingling or numbness) reflects nerve function and can reveal nerve damage or compromised blood flow, necessitating thorough evaluation.
Choice E rationale
Pain assessment is crucial for identifying the severity of injury and potential complications such as compartment syndrome. Pain disproportionate to the injury suggests complications.
Choice F rationale
Palpating pulses assesses blood flow, ensuring the presence of distal perfusion. Absent or weak pulses require urgent vascular intervention to prevent tissue necrosis.
Correct Answer is D,B,E,A,C
No explanation
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