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. Increased LOC (level of consciousness) and increased range of motion are not typical symptoms of increased intracranial pressure (ICP). In fact, ICP usually leads to a decreased level of consciousness, not an increase.

B. Restlessness, irritability, and decreased LOC are early signs of increased intracranial pressure. As pressure inside the skull rises, the brain becomes less able to function normally, leading to changes in behavior and cognition, such as restlessness and irritability, followed by a decrease in consciousness.

C. Pain in the calf and neck is not a typical symptom of ICP. While neck pain may occur with certain neurological conditions, it is not a hallmark of increased intracranial pressure.

D. Fever and chills are not initial symptoms of ICP. These symptoms are more indicative of infection, such as meningitis, rather than increased intracranial pressure.

A. Assist the client to sit upright in a chair for 4 hr at a time. B. Expect clear drainage on the spinal dressing. C. Elevate the client's legs when he is lying on his side. D. Log roll the client every 2 hr.

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.

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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

What are the initial symptoms of ICP (increased intracranial pressure)?

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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