A nurse is caring for a client who has a cerebral aneurysm. In the event of a ruptured cerebral aneurysm, which of the following manifestations would be present in the client?
(Select All that Apply.)

Choice A Reason:

Decreased blood pressure is correct. Decreased blood pressure (hypotension) is the priority finding to monitor for because it is indicative of a severe allergic reaction known as anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can lead to shock, organ failure, and death if not promptly treated. Hypotension in the context of an allergic reaction suggests widespread vasodilation and increased vascular permeability, resulting in a decrease in blood pressure.

Choice B Reason:

Stomach pain is incorrect. Stomach pain may indicate gastrointestinal distress or adverse effects of the antibiotic, but it is not typically as immediately life-threatening as decreased blood pressure in the context of anaphylaxis. While abdominal pain should not be ignored, it is not the priority finding when assessing for signs of anaphylaxis.

Choice C Reason:

Urticaria is incorrect. Urticaria, also known as hives, is a common allergic reaction characterized by raised, itchy welts on the skin. While urticaria can be uncomfortable and distressing, it is not immediately life-threatening. However, urticaria may be a precursor to more severe allergic reactions, such as anaphylaxis, so it is still important to monitor closely.

Choice D Reason:

Lightheadedness is incorrect. Lightheadedness may occur as a result of hypotension in the context of anaphylaxis, but it is not as critical as directly monitoring blood pressure. Lightheadedness may also be caused by other factors, such as anxiety or dehydration, and may not always indicate a severe allergic reaction. While it is important to assess for lightheadedness and monitor the client's overall condition, it is not the priority finding compared to decreased blood pressure.

Choice A Reason:

Vasogenic cerebral edema is appropriate response. Vasogenic cerebral edema occurs due to disruption of the blood-brain barrier (BBB), leading to leakage of fluid and proteins from the blood vessels into the brain parenchyma. This type of cerebral edema is commonly associated with conditions such as brain tumors, abscesses, and ischemic stroke.

Choice B Reason:

Osmotic cerebral edema is inappropriate response. Osmotic cerebral edema occurs when there is an imbalance of osmotic forces across the blood-brain barrier, leading to the movement of water into the brain cells. This type of cerebral edema can result from conditions such as hyponatremia or the administration of hypertonic solutions.

Choice C Reason:

Cellular cerebral edema is inappropriate response. Cellular cerebral edema involves the swelling of brain cells (neurons and glial cells) due to various insults, such as ischemia, hypoxia, or metabolic disturbances. This type of cerebral edema can occur in conditions such as ischemic stroke or traumatic brain injury.

Choice D Reason:

Interstitial cerebral edema is incorrect response. Interstitial cerebral edema involves the accumulation of fluid within the interstitial spaces of the brain tissue. This type of cerebral edema can occur in conditions such as hydrocephalus, where there is obstruction of cerebrospinal fluid (CSF) flow.