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The patient presents with a complaint of "always dropping things and falling down." During the neurologic assessment, the nurse observes that the patient's display of rapid alternating movements is slow and misses often. The patient also loses balance during the Romberg Test. What neurologic problem would the nurse suspect?

Lesion of cranial nerve IX

Vestibular disease

Dysfunction of the cerebellum

Arteriovenous malformation (AVM) at frontal lobe

Answer and Explanation

The Correct Answer is C

A. A lesion of cranial nerve IX primarily affects swallowing and taste sensations rather than motor coordination or balance, so this is unlikely to explain the patient's symptoms.

B. Vestibular disease typically results in vertigo and balance issues, but the specific observations of slow alternating movements and loss of balance during the Romberg Test suggest a different underlying cause.

C. Dysfunction of the cerebellum would explain the patient's difficulties with rapid alternating movements and balance issues, as the cerebellum is responsible for coordinating motor activity and maintaining posture and balance. This aligns with the assessment findings, indicating a probable cerebellar dysfunction.

D. While an AVM in the frontal lobe could affect motor control, the specific symptoms presented, such as the inability to perform rapid movements and balance issues, are more characteristic of cerebellar dysfunction rather than a frontal lobe lesion.

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A. Administer a narcotic analgesic every two hours. B. Encourage a low-fat diet the first post-op day. C. Encourage the use of the incentive spirometer. D. Ambulate the client in the hall the first post-op evening.

Correct Answer is C

Explanation

A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.

B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.

C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.

D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.

A. Degree of upper body vasculature observed. B. Arm circumference and degree of edema. C. Blood pressure and heart rate. D. Peripheral sensation and movement of upper extremities.

Correct Answer is C

Explanation

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.

B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.

C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.

D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

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Correct Answer is C

Explanation

Correct Answer is C

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The nurse is caring for a client post-operatively following an open (incisional) cholecystectomy. Which would be the priority nursing intervention for this client?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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