A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse’s priority?
Provide assistance with ambulation.
Facilitate retention of facts by repeating instructions.
Place the client in a darkened room.
Speak slowly and clearly.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
The dressing for a PICC line should be changed every 7 days or sooner if it becomes wet, soiled, or loose. Therefore, a dressing change 7 days ago is within the recommended guidelines and does not necessarily require immediate notification of the provider.
Choice B Reason:
An increase in the circumference of the client’s upper arm by 10% can indicate swelling, which may be a sign of complications such as infection, thrombosis, or infiltration. This finding should be promptly reported to the provider for further evaluation and intervention.
Choice C Reason:
The catheter not being used for 8 hours is not typically a cause for concern as long as it is properly flushed and maintained. PICC lines can remain in place for extended periods without use, provided they are flushed regularly to prevent occlusion.
Choice D Reason:
Flushing the catheter with 10 mL of sterile saline after medication use is a standard practice to maintain patency and prevent blockage This action does not require notification of the provider unless there are other associated complications.
Correct Answer is D
Explanation
Choice A Reason
“Your provider will use stool from your digital rectal examination to perform the test.” This statement is incorrect. For fecal occult blood testing, stool samples are typically collected at home using a special kit provided by the healthcare provider. The samples are then sent to a lab for analysis. Using stool from a digital rectal examination is not the standard procedure for FOBT.
Choice B Reason
“Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel.” This statement is incorrect. Stimulant laxatives are not typically prescribed before an FOBT. The test requires a small sample of stool, and using a laxative could interfere with the results. Patients are usually advised to follow specific dietary and medication guidelines to avoid false positives or negatives.
Choice C Reason
“You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old.” This statement is incorrect. Current guidelines recommend starting colorectal cancer screening, including FOBT, at age 45 for individuals at average risk. Screening may start earlier for those with a higher risk, such as a family history of colorectal cancer.
Choice D Reason
“You should avoid taking corticosteroids prior to testing.” This is the correct statement. Corticosteroids can cause gastrointestinal irritation and bleeding, which may lead to false-positive results in fecal occult blood tests. Therefore, it is important to avoid these medications before testing.
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