The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

Ensure bed alarm is on when leaving patient's room

Vary schedule to prevent memorization and boredom

Clarify misinformation and reorient when confused

Deep breathing and incentive spirometer education

Answer and Explanation

The Correct Answer is A

A) Ensure bed alarm is on when leaving patient's room:
The cerebellum plays a critical role in coordinating movement, balance, and motor control. An injury to this area can lead to impaired coordination and dysfunction in balance, making it difficult for the patient to perform the Romberg test (which evaluates balance and proprioception). Given that the patient cannot complete the Romberg test, this suggests the risk of falling or injuring themselves due to impaired balance and coordination. The priority nursing intervention is to ensure safety by using a bed alarm to alert staff if the patient attempts to get out of bed, thereby preventing falls.

B) Vary schedule to prevent memorization and boredom:
While changing the patient's routine may help with engagement, it is not the priority intervention for a patient with cerebellar injury. The primary concern in this situation is safety due to the patient's impaired balance. Addressing issues related to cognitive function or boredom may be important but comes after ensuring the patient’s physical safety.

C) Clarify misinformation and reorient when confused:
Reorientation may be necessary if the patient is confused or disoriented, but this is not the primary concern related to cerebellar injury. The patient’s balance and motor coordination are the most pressing issues. While mental clarity is important, preventing falls due to impaired motor control is the immediate priority.

D) Deep breathing and incentive spirometer education:
Deep breathing exercises and using an incentive spirometer are essential to prevent respiratory complications, particularly after surgery or immobility. However, in this case, the priority concern is the patient's safety related to impaired balance from the cerebellar injury. Respiratory interventions are important but should be addressed after ensuring that the patient is safe from falls and other immediate physical risks.

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Correct Answer is A

Explanation

A) Dyspnea, crackles, hypertension, and edema:
These symptoms suggest a transfusion-related acute lung injury (TRALI) or circulatory overload (TACO), both of which are potentially life-threatening conditions. In cases of TRALI or TACO, the nurse should stop the transfusion immediately but should NOT administer 0.9% normal saline because saline could exacerbate fluid overload and worsen pulmonary edema. Instead, the nurse should focus on managing respiratory distress, ensuring proper oxygenation, and notifying the healthcare provider for further intervention.

B) Low back pain, hypotension, and tachycardia:
These symptoms are typically indicative of a hemolytic transfusion reaction (HTR), which requires immediate intervention. In this case, the transfusion should be stopped immediately, but the nurse should begin administering 0.9% normal saline to help maintain the patient's blood pressure and promote kidney perfusion to prevent renal damage.

C) Urticaria, itching, wheezing, angioedema:
These symptoms are characteristic of a mild allergic reaction to the blood transfusion. In this case, the nurse should stop the transfusion and administer 0.9% normal saline to maintain the patient’s hydration and blood pressure while managing the allergic reaction. The healthcare provider may order antihistamines or corticosteroids to treat the allergic symptoms.

D) Chest tightness, fever, chills/rigors:
These are common symptoms of a febrile non-hemolytic transfusion reaction (FNHTR), which is generally not life-threatening. The nurse should stop the transfusion but can continue administering 0.9% normal saline to support hydration and circulation. FNHTR is often managed with antipyretics (e.g., acetaminophen) to reduce fever and chills, and the transfusion may be resumed if symptoms resolve

A. chemical burns to the posterior neck, chest, and back B. radiation burns to shoulder and bridge of nose C. electrical burns to the hands causing dysrhythmias D. thermal burns to the head, neck, face, and airway.

Correct Answer is D

Explanation

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

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The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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