The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

Clarify misinformation and reorient when confused

Turn patient every 2 hours

Ensure bed alarm is on when leaving the patient's room

Vary schedule to prevent memorization and boredom

Answer and Explanation

The Correct Answer is C

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

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Correct Answer is ["A","C","E"]

Explanation

A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.

B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.

C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.

D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.

E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.

A. Fifth intercostal space, left midclavicular line B. Fourth intercostal space, right sternal boarder C. Third intercostal space, left midclavicular line D. Second intercostal space, right sternal boarder

Correct Answer is A

Explanation

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

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The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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