A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse’s priority?

Provide assistance with ambulation.

Facilitate retention of facts by repeating instructions.

Place the client in a darkened room.

Speak slowly and clearly.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Provide assistance with ambulation: Patients with cerebellar tumors often experience ataxia, which is a lack of muscle coordination affecting voluntary movements such as walking and balance. Assisting with ambulation is crucial to prevent falls and ensure the patient’s safety. The cerebellum plays a significant role in motor control, and damage to this area can severely impair a patient’s ability to move safely. Therefore, providing assistance with ambulation is a priority to prevent injury and promote mobility.

Choice B Reason:

Facilitate retention of facts by repeating instructions: While repeating instructions can be beneficial for patients with cognitive impairments, it is not the primary concern for a patient with a cerebellar tumor. The main issues with cerebellar tumors are related to motor control and balance. Although cognitive support is important, ensuring physical safety through assistance with ambulation takes precedence.

Choice C Reason:

Place the client in a darkened room: Placing a patient in a darkened room might help with symptoms like photophobia (sensitivity to light), but it does not address the primary concerns associated with cerebellar tumors, such as balance and coordination. This action does not directly contribute to the patient’s immediate safety and mobility needs.

Choice D Reason:

Speak slowly and clearly: Clear communication is always important in nursing care, especially for patients who may have difficulty understanding due to neurological issues. However, for a patient with a cerebellar tumor, the immediate priority is to address motor dysfunction and prevent falls. Speaking slowly and clearly is supportive but not the primary action needed to ensure the patient’s safety.

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Correct Answer is B

Explanation

Choice A Reason:

Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg). This condition occurs when there is an accumulation of carbon dioxide in the blood due to hypoventilation or impaired lung function. In this case, the client’s pH is elevated, and PaCO₂ is low, which does not align with respiratory acidosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (above 7.45) and a low PaCO₂ (below 35 mm Hg). This condition results from hyperventilation, which causes excessive exhalation of carbon dioxide. The client’s ABG results show a pH of 7.50 and a PaCO₂ of 29 mm Hg, consistent with respiratory alkalosis.

Choice C Reason:

Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO₃ (below 21 mEq/L). This condition occurs due to an accumulation of acids or a loss of bicarbonate in the body. The client’s pH is elevated, and HCO₃ is within the normal range, which does not indicate metabolic acidosis.

Choice D Reason:

Metabolic alkalosis is indicated by a high pH (above 7.45) and a high HCO₃ (above 28 mEq/L). This condition results from an excess of bicarbonate or a loss of acids. The client’s pH is elevated, but HCO₃ is within the normal range, which does not support a diagnosis of metabolic alkalosis.

A. Axillary temperature 37.2° C (99° F) B. Apical pulse 100/min C. Respiratory rate 30/min D. Blood pressure 140/84 mm Hg

Correct Answer is C

Explanation

Choice A Reason

Axillary temperature 37.2° C (99° F). This temperature is within the normal range and does not indicate an immediate need for intervention. Normal body temperature ranges from 36.1° C to 37.2° C (97° F to 99° F).

Choice B Reason

Apical pulse 100/min. While a pulse rate of 100 beats per minute is on the higher end of the normal range, it is not necessarily indicative of an immediate life-threatening condition. Normal resting heart rate for adults ranges from 60 to 100 beats per minute.

Choice C Reason

Respiratory rate 30/min. This is the correct answer. A respiratory rate of 30 breaths per minute is significantly higher than the normal range of 12 to 20 breaths per minute for adults. This could indicate respiratory distress or other complications that require immediate intervention.

Choice D Reason

Blood pressure 140/84 mm Hg. While this blood pressure reading is elevated and may require monitoring, it does not indicate an immediate life-threatening condition. Normal blood pressure is typically around 120/80 mm Hg, but a reading of 140/84 mm Hg is not uncommon and can be managed with appropriate care.

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A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO₂ 29 mm Hg (35 to 45 mm Hg), and HCO₃ 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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