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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Prolonged prothrombin time (PT):
A prolonged PT is a sign of impaired coagulation, which is common in DIC as the clotting factors are consumed. In DIC, both clotting and bleeding occur, leading to prolonged PT. Therefore, a prolonged PT does not reflect a positive outcome. A positive outcome would show normalization or improvement of the clotting profile.

B) Elevated fibrinogen level:
Fibrinogen is often decreased in DIC because it is consumed in the process of forming clots. An elevated fibrinogen level would not indicate a positive outcome in DIC. Instead, fibrinogen levels typically fall in DIC due to widespread clotting activity. A positive outcome would involve a normalization or increase in fibrinogen levels as the condition improves.

C) Decreased platelet count:
Platelet count typically decreases in DIC because platelets are used up in the formation of clots, leading to thrombocytopenia. A decreased platelet count reflects ongoing consumption of platelets and would not be a positive indicator of improvement. In a positive outcome, the platelet count would increase toward normal levels.

D) Decreased D-dimer level:
D-dimer is a product of fibrin degradation and is elevated in conditions like DIC, where abnormal clotting and fibrinolysis are occurring. A decreased D-dimer level indicates that the coagulation process is resolving, and fibrin degradation is returning to normal, reflecting a positive outcome. Monitoring the D-dimer level is a key indicator of improvement in DIC.

A. prevent the drainage by applying a tight pressure dressing B. administer antibiotics due to increased risk of infection C. allow fluid to drain from the patient's car onto gauze and notify D. hang intravenous (IV) fluids to replace fluids lost and prevent dehydration

Correct Answer is C

Explanation

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 evaluating the outcomes for a client diagnosed with disseminated intravascular coagulation (DIC). Which laboratory value reflects a positive outcome?

Correct Answer is D

Explanation

The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

Correct Answer is C

Explanation

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).

The nurse is providing education to the client diagnosed with multiple sclerosis (MS) about baclofen. What statement made by the client would indicate to the nurse that the client understood the education? The client states ‘’I will

A nurse is teaching a client newly diagnosed with a seizure disorder about phenytoin sodium therapy. What information should the nurse stress regarding the client stopping the drug suddenly? The drug should not be stopped abruptly because:

A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

The nurse is caring for client who is four days post-operative open repair of an abdominal aortic aneurysm the abdomen is distended. The client is complaining abdominal pain and the abdomen is distended. What action should the nurse take at this time?