The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

Ensure bed alarm is on when leaving patient's room

Vary schedule to prevent memorization and boredom

Clarify misinformation and reorient when confused

Deep breathing and incentive spirometer education

Answer and Explanation

The Correct Answer is A

A) Ensure bed alarm is on when leaving patient's room:
The cerebellum plays a critical role in coordinating movement, balance, and motor control. An injury to this area can lead to impaired coordination and dysfunction in balance, making it difficult for the patient to perform the Romberg test (which evaluates balance and proprioception). Given that the patient cannot complete the Romberg test, this suggests the risk of falling or injuring themselves due to impaired balance and coordination. The priority nursing intervention is to ensure safety by using a bed alarm to alert staff if the patient attempts to get out of bed, thereby preventing falls.

B) Vary schedule to prevent memorization and boredom:
While changing the patient's routine may help with engagement, it is not the priority intervention for a patient with cerebellar injury. The primary concern in this situation is safety due to the patient's impaired balance. Addressing issues related to cognitive function or boredom may be important but comes after ensuring the patient’s physical safety.

C) Clarify misinformation and reorient when confused:
Reorientation may be necessary if the patient is confused or disoriented, but this is not the primary concern related to cerebellar injury. The patient’s balance and motor coordination are the most pressing issues. While mental clarity is important, preventing falls due to impaired motor control is the immediate priority.

D) Deep breathing and incentive spirometer education:
Deep breathing exercises and using an incentive spirometer are essential to prevent respiratory complications, particularly after surgery or immobility. However, in this case, the priority concern is the patient's safety related to impaired balance from the cerebellar injury. Respiratory interventions are important but should be addressed after ensuring that the patient is safe from falls and other immediate physical risks.

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Correct Answer is B

Explanation

A) Fever and cardiac dysrhythmias:
Fever and cardiac dysrhythmias are not the hallmark signs of an intracerebral hemorrhage (ICH) following thrombolytic therapy. While fever can occur in the aftermath of a stroke, it is more commonly linked to infection or other complications. Cardiac dysrhythmias can occur in stroke patients due to autonomic dysfunction or other underlying conditions but are not specific to a hemorrhagic complication.

B) Decline in neurological status and elevated blood pressure:
A decline in neurological status (e.g., deterioration of consciousness, confusion, or focal deficits) and elevated blood pressure are classic signs of an intracerebral hemorrhage (ICH) following thrombolytic therapy, especially when tissue plasminogen activator (tPA) is administered. tPA works by dissolving blood clots but increases the risk of bleeding. An ICH could present with sudden worsening neurological symptoms, such as decreased level of consciousness, weakness, or sensory loss, and elevated blood pressure is a compensatory response to the hemorrhage.

C) Abdominal distention and anorexia:
Abdominal distention and anorexia are not typical indicators of an intracerebral hemorrhage following tPA therapy. These symptoms may indicate other issues, such as gastrointestinal problems or metabolic imbalances, but they are not directly related to hemorrhagic complications following thrombolytic therapy for stroke.

D) Positive Coombs test and low urine output:
A positive Coombs test indicates the presence of antibodies against red blood cells, which may suggest hemolytic anemia or an autoimmune process. Low urine output can result from a variety of conditions, including kidney dysfunction, dehydration, or shock, but these are not specific indicators of an intracerebral hemorrhage following tPA.

A. use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10 B. print a 1-minute EGG strip and count the number of QRS complexes C. calculate the number of small squares between one QRS complexes and the next one and divide by 1500 D. count the number of large squares in the R-R interval and divide by 300

Correct Answer is A

Explanation

A) Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10:
The 3-second markers on the ECG strip represent a fixed time interval. By counting the number of QRS complexes in the 6-second interval (i.e., two 3-second markers), you can estimate the heart rate by multiplying the number of QRS complexes by 10. This method is quick and effective for calculating heart rate in an emergency setting, such as in arrhythmias or when time is of the essence.

B) Print a 1-minute ECG strip and count the number of QRS complexes:
While this is another way to assess the heart rate, it is not a quick method, especially in emergency situations. It is more time-consuming because it involves printing out a full strip (or ensuring you have enough data to calculate a full minute). This approach may be useful for detailed analysis but is not optimal for quickly estimating the ventricular rhythm.

C) Calculate the number of small squares between one QRS complex and the next one and divide by 1500:
This method is more complex and is used for calculating the heart rate with a more precise ECG reading. It requires counting the number of small squares between two QRS complexes and dividing by 1500 (the number of small squares in one minute). This method is accurate but not the fastest option for quickly estimating the heart rate during an emergency.

D) Count the number of large squares in the R-R interval and divide by 300:
counting the number of large squares between two R-R intervals and dividing by 300, you get the heart rate. However, this method is less commonly used in emergency situations because it requires more time and may not be as immediate as using the 3-second markers. It is more applicable when doing a detailed analysis of the rhythm.

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The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for client who has had a stroke and who received tissue plasminogen activator(t-PA) 6 hours ago. The nurse identifies which of the following symptoms are indications of an intracerebral hemorrhage post thrombolytic therapy?

Correct Answer is B

Explanation

When using an ECG rhythm strip to quickly estimate the ventricular rhythm for a client, the nurse should:

Correct Answer is A

Explanation

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