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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason

“You are not contagious when lesions are healed.” This statement is incorrect. Genital herpes can still be contagious even when there are no visible lesions. The virus can be shed from the skin and transmitted to others even in the absence of symptoms.

Choice B Reason

“This infection is spread through the air.” This statement is incorrect. Genital herpes is not spread through the air. It is primarily transmitted through direct skin-to-skin contact, particularly during sexual activity.

Choice C Reason

“Stress can activate an outbreak.” This statement is correct. Stress is a known trigger for reactivation of the herpes simplex virus, leading to outbreaks of genital herpes. Other triggers can include illness, fatigue, and immune suppression.

Choice D Reason

“Antiviral drugs will cure the infection.” This statement is incorrect. While antiviral drugs can help manage symptoms and reduce the frequency of outbreaks, they do not cure the infection. The herpes simplex virus remains in the body and can reactivate.

A. A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. B. A client who received parenteral cephalosporin and reports urticaria and edema. C. A client who is being admitted with bilateral stage 3 pressure injuries on both heels. D. A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F).

Correct Answer is B

Explanation

Choice A Reason

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.

Choice B Reason

A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.

Choice C Reason

A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.

Choice D Reason

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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