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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.
B. Tachycardia and dry cough are not common side effects of timolol; dry cough is more associated with ACE inhibitors.
C. Scleral injection and tearing are not common side effects and are not expected with timolol use.
D. Changes in eye pigmentation are more commonly seen with prostaglandin analogs, not with beta-blockers like timolol.
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.
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