A client has a herniated lumbar disk at L5. The nurse knows that which of the following symptoms needs to be immediately reported to the RN or physician?
Bowel or bladder incontinence
Lower back pain
Muscle spasms
Pain radiating down one leg
The Correct Answer is A
A. Bowel or bladder incontinence is a medical emergency and should be immediately reported. This symptom can indicate cauda equina syndrome, a condition caused by compression of the spinal nerves at the lower end of the spinal cord. This requires urgent surgical intervention to prevent permanent nerve damage.
B. Lower back pain is a common symptom of a herniated lumbar disk, but it is not an immediate emergency unless accompanied by other severe symptoms.
C. Muscle spasms are also common with a herniated disk and, while uncomfortable, are not immediately life-threatening.
D. Pain radiating down one leg (sciatica) is a typical symptom of a herniated lumbar disk and is often managed conservatively, unless it is severe or accompanied by other neurological deficits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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