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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To administer the correct dose of Morphine, the nurse needs to calculate the volume of medication to deliver 1 mg of Morphine. Since the medication is supplied in a concentration of 2 mg per 1 mL, the nurse would administer half of the volume of the vial to provide the ordered 1 mg dose. Therefore, the nurse should administer 0.5 mL of Morphine to the patient.
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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