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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.

B. Tachycardia and hypotension are not primary indicators of elevated ICP.

C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.

D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.

A. Bradycardia B. Sepsis C. Hypertension D. Respiratory compromise

Correct Answer is D

Explanation

A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.

B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.

C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.

D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.

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The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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