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
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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Related Questions
Correct Answer is B
Explanation
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
Correct Answer is D
Explanation
A. Using a draw sheet may cause twisting, which can compromise spinal alignment.
B. Asking the patient to assist may risk further spinal injury.
C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.
D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.
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