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 D
Explanation
Choice A rationale
Chewing gum can increase salivary production, and while saliva may neutralize some stomach acid, the act of chewing can stimulate swallowing and possibly exacerbate symptoms by introducing excess air into the stomach. For GERD patients, avoiding gum may help reduce bloating and gas discomfort.
Choice B rationale
Elevating the head of the bed reduces the likelihood of acid reflux during sleep by using gravity to prevent stomach contents from flowing backward into the esophagus. This strategy aligns with GERD management guidelines and reduces nighttime symptoms.
Choice C rationale
Taking antacids between meals and at bedtime helps neutralize stomach acid temporarily, providing short-term relief of GERD symptoms. While effective, long-term use without addressing dietary and lifestyle factors is not ideal for managing GERD.
Choice D rationale
Eating small meals is beneficial for GERD, as it prevents overdistension of the stomach, but having a bedtime snack contradicts GERD management principles. Late-night eating may increase the risk of acid reflux when lying down, thus requiring more teaching.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Using a urine filter ensures the recovery of passed stones for laboratory analysis, assisting in identifying stone composition and tailoring prevention strategies.
Choice B rationale
Calcium intake is essential for bone health and reducing oxalate absorption. Avoiding calcium increases oxalate availability, worsening stone formation.
Choice C rationale
Diuretic fluids like coffee promote dehydration and concentration of urine, increasing the risk of stone recurrence. Diuretics should be prescribed for specific stone types.
Choice D rationale
Maintaining hydration prevents urine concentration and the supersaturation of stone-forming crystals, which are primary risk factors for nephrolithiasis.
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