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 D
Explanation
Choice A Reason:
The statement that “Your provider will use your digital rectal examination to perform the test” is incorrect. A fecal occult blood test (FOBT) typically involves collecting stool samples at home over several days, not during a digital rectal examination. The samples are then sent to a lab for analysis to detect hidden blood in the stool.
Choice B Reason:
The statement that “Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel” is also incorrect. There is no need for a stimulant laxative before an FOBT. The test requires normal bowel movements to detect any hidden blood in the stool.
Choice C Reason:
The recommendation to “begin annual fecal occult blood testing for colorectal cancer screening at 40 years old” is not accurate. Current guidelines generally recommend starting colorectal cancer screening at age 45 for individuals at average risk. However, those with higher risk factors may need to start earlier, based on their healthcare provider’s advice.
Choice D Reason:
The statement “You should avoid taking corticosteroids prior to testing” is correct. Certain medications, including corticosteroids, can cause gastrointestinal bleeding, which may lead to false-positive results in an FOBT. Therefore, it is important to avoid these medications before the test, as advised by a healthcare provider.
Correct Answer is C
Explanation
Choice A Reason
“Tube drainage should be rust-colored.” This statement is incorrect. Normal NG tube drainage is typically greenish-yellow due to bile or clear if it is from the stomach. Rust-colored drainage could indicate bleeding and should be reported immediately.
Choice B Reason
“Nutrition will be provided through the tube.” This statement is incorrect. While NG tubes can be used for feeding, in the context of a postoperative colectomy, the primary purpose of the NG tube is usually to decompress the stomach and prevent nausea and vomiting. Enteral feeding is typically done through a different type of tube, such as a nasojejunal tube.
Choice C Reason
“The tube decreases pressure within the stomach.” This is the correct statement. An NG tube is often used postoperatively to decompress the stomach, which helps to reduce pressure, prevent vomiting, and allow the gastrointestinal tract to heal.
Choice D Reason
“The tube should be irrigated with sterile water.” This statement is partially correct but needs context. NG tubes should be irrigated to maintain patency, but the type of solution (sterile water, saline) can vary based on hospital protocol. The primary focus here is on the purpose of the NG tube rather than the irrigation technique.
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