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 ["12"]

Explanation

Given:

Ordered dose of Heparin: 20 units/kg

Patient weight: 132 lbs

Concentration of Heparin: 25,000 units/250 mL (100 units/mL)

Step 1: Convert patient weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Patient weight in kg = 132 lbs x 0.453592 kg/lb = 59.87424 kg

Step 2: Calculate the total dose of Heparin:

Total dose (units) = Ordered dose (units/kg) x Patient weight (kg)

Total dose (units) = 20 units/kg x 59.87424 kg

Total dose (units) = 1197.4848 units

Step 3: Calculate the volume to be administered:

Volume (mL) = Total dose (units) / Concentration (units/mL)

Volume (mL) = 1197.4848 units / 100 units/mL

Volume (mL) = 11.974848 mL

Step 4: Round to the nearest whole number:

Volume (mL) ≈ 12 mL

A. Take the prescribed anticoagulant specifically as directed B. Stop taking your antihypertensive medications until checking with your surgeon C. Avoid lifting objects ten pounds or greater for two days D. Take your immunosuppressive medications daily in the morning

Correct Answer is A

Explanation

A) Take the prescribed anticoagulant specifically as directed:
Clients with mechanical heart valves are at an increased risk of developing blood clots, and therefore, anticoagulation therapy (often warfarin or another blood thinner) is necessary to prevent thromboembolic events. It is essential for the client to take the prescribed anticoagulant exactly as directed, ensuring therapeutic levels are maintained while minimizing the risk of bleeding.

B) Stop taking your antihypertensive medications until checking:
This instruction is not appropriate after heart surgery. Antihypertensive medications are typically necessary to manage blood pressure and reduce the strain on the heart. Stopping antihypertensive medications without consulting the healthcare provider could result in elevated blood pressure, which can put undue stress on the heart, especially after valve replacement surgery.

C) Avoid lifting objects ten pounds or greater for two days:
This statement is not appropriate for a client who has undergone open heart surgery. After heart surgery, particularly valve replacement, the client may be advised to avoid lifting heavy objects for a period of time (often 4-6 weeks) to prevent strain on the incision site and the heart. Two days of restriction is insufficient; longer periods of activity limitation are usually required to ensure proper healing.

D) Take your immunosuppressive medications daily in the morning:
Immunosuppressive medications are not typically prescribed for clients with mechanical heart valves. Immunosuppressive drugs are usually prescribed for clients who have had organ transplants (e.g., kidney, liver) to prevent organ rejection. Since the client in this scenario had a mitral valve replacement, immunosuppressants are not usually indicated unless there are specific complications, such as endocarditis or other infections.

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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

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 132 lbs. The medication is supplied as 25,000 units/250 mL. How many mL will the nurse give? (round to the nearest whole number)

Correct Answer is ["12"]

Explanation

The client who has had open heart surgery for a mitral valve replacement with a mechanical valve is preparing for discharge. Which information should the nurse include in the teaching?

Correct Answer is A

Explanation

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