A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?

Choice A Reason:

Provide assistance with ambulation: Patients with cerebellar tumors often experience ataxia, which is a lack of muscle coordination affecting voluntary movements such as walking and balance. Assisting with ambulation is crucial to prevent falls and ensure the patient’s safety. The cerebellum plays a significant role in motor control, and damage to this area can severely impair a patient’s ability to move safely. Therefore, providing assistance with ambulation is a priority to prevent injury and promote mobility.

Choice B Reason:

Facilitate retention of facts by repeating instructions: While repeating instructions can be beneficial for patients with cognitive impairments, it is not the primary concern for a patient with a cerebellar tumor. The main issues with cerebellar tumors are related to motor control and balance. Although cognitive support is important, ensuring physical safety through assistance with ambulation takes precedence.

Choice C Reason:

Place the client in a darkened room: Placing a patient in a darkened room might help with symptoms like photophobia (sensitivity to light), but it does not address the primary concerns associated with cerebellar tumors, such as balance and coordination. This action does not directly contribute to the patient’s immediate safety and mobility needs.

Choice D Reason:

Speak slowly and clearly: Clear communication is always important in nursing care, especially for patients who may have difficulty understanding due to neurological issues. However, for a patient with a cerebellar tumor, the immediate priority is to address motor dysfunction and prevent falls. Speaking slowly and clearly is supportive but not the primary action needed to ensure the patient’s safety.

Choice A Reason

4g sodium diet. While reducing sodium intake is important for managing chronic kidney disease (CKD), a specific 4g sodium diet is not typically prescribed. Instead, patients are generally advised to limit sodium intake to less than 2,300 milligrams per day to help control blood pressure and reduce fluid retention.

Choice B Reason

Potassium-restricted diet. This is the correct intervention. Patients with CKD often have difficulty excreting potassium, leading to hyperkalemia, which can be dangerous. Therefore, a potassium-restricted diet is commonly recommended to maintain normal serum potassium levels.

Choice C Reason

High-phosphorus diet. This statement is incorrect. Patients with CKD are usually advised to limit phosphorus intake because their kidneys cannot effectively excrete phosphorus, leading to hyperphosphatemia. High phosphorus levels can cause bone and cardiovascular problems.

Choice D Reason

High-protein diet. This statement is incorrect. While protein is essential, excessive protein intake can increase the workload on the kidneys. Patients with CKD are often advised to follow a moderate protein diet to reduce the production of waste products that the kidneys need to filter.