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. A severe headache, often described as a "thunderclap" headache or the worst headache of the patient’s life, is a classic symptom of subarachnoid hemorrhage due to irritation of the meninges and increased intracranial pressure.
B. Generalized weakness may occur in some neurological conditions but is not a hallmark symptom of subarachnoid hemorrhage.
C. Gradual blurry vision is more associated with conditions like increased intracranial pressure or other eye-related issues rather than acute subarachnoid hemorrhage.
D. Chest pain is not typically associated with subarachnoid hemorrhage; it may indicate other conditions such as myocardial infarction or pulmonary issues.
Correct Answer is C
Explanation
A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.
B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.
C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.
D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.
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