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 D

Explanation

A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.

B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.

C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.

D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.

A. an anxiety disorder. B. related to hunger. C. an aura. D. a postictal sign.

Correct Answer is C

Explanation

A. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.

B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.

C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.

D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.

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

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who was given a new medical prescription for phenytoin. What would the nurse stress in the discharge instructions regarding this medication?

Correct Answer is D

Explanation

A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:

Correct Answer is C

Explanation

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

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