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. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.

B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.

C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.

D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.

A. Nitroprusside B. Furosemide C. 3% Normal Saline D. Norepinephrine

Correct Answer is C

Explanation

A. Nitroprusside is a vasodilator and is not used for managing ICP; it can increase intracranial pressure if not carefully monitored.

B. Furosemide is a diuretic but is less effective for ICP reduction compared to hypertonic saline or mannitol.

C. Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.

D. Norepinephrine is a vasopressor and is not used specifically to manage intracranial pressure.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

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 emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Correct Answer is D

Explanation

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?

Correct Answer is C

Explanation

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