A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
Complaint of headache off and on for past month.
Nausea.
No bowel movement since yesterday.
Frequent voiding.
The Correct Answer is A
complaint of headaches off and on for the past month. A cerebral aneurysm is a bulging or ballooning in a blood vessel in the brain that can cause severe headaches or rupture, leading to bleeding in the brain. Therefore, a complaint of a headache is of greatest concern and requires immediate attention.
Nausea (B) is a common symptom associated with many disorders, and it may or may not be related to a cerebral aneurysm. No bowel movement since yesterday
(C) and frequent voiding (D) are not specific to cerebral aneurysms and may be caused by various other factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E"}
Explanation
Brudzinski sign is a clinical sign of meningitis, an inflammation of the membranes that cover the brain and spinal cord. It is characterized by reflexive flexion of the knees and hips following passive neck flexion13. To test for this sign, the examiner places one hand on the chest and the other behind the neck of the patient lying flat on the back, and then lifts the head forward. Brudzinski sign was first described by Polish pediatrician Józef Brudziński over 100 years ago. It may be absent, especially in young children.
Correct Answer is B
Explanation
In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.
Choice A is incorrect because it describes the Weber test, not the Rinne test.
Choice C is incorrect because it is not a standard hearing test.
Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.
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