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.)
Light sensitivity
Loss of consciousness
A dilated pupil
Visual disturbances
Nausea and vomiting
Numbness on one side of the face
Correct Answer : B,C,D,E
Choice A Reason:
Light sensitivity is incorrect. Light sensitivity (photophobia) is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur as a secondary symptom due to other neurological disturbances or increased intracranial pressure.
Choice B Reason:
Loss of consciousness is correct. Loss of consciousness is a common manifestation of a ruptured cerebral aneurysm, particularly if the bleeding leads to significant brain injury or compression of vital brain structures.
Choice C Reason:
A dilated pupil is correct. A dilated pupil (mydriasis) may occur as a result of compression of the oculomotor nerve (cranial nerve III) by the expanding hematoma or increased intracranial pressure following a ruptured cerebral aneurysm.
Choice D Reason:
Visual disturbances is correct. Visual disturbances, such as blurred vision, double vision (diplopia), or loss of vision, may occur due to compression of the optic nerve or damage to visual pathways as a result of the hemorrhage.
Choice E Reason:
Nausea and vomiting is correct. Nausea and vomiting are common symptoms associated with a ruptured cerebral aneurysm, often due to irritation of the meninges and increased intracranial pressure resulting from the bleeding.
Choice F Reason:
Numbness on one side of the face is incorrect. Numbness on one side of the face is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur if the hemorrhage affects specific regions of the brain responsible for sensation or if there is associated compression of cranial nerves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Choice A Reason:
Sedatives do not impact the risk of obstructive sleep apnea: This statement is incorrect. Sedatives, particularly those that cause muscle relaxation or depress the central nervous system, can exacerbate obstructive sleep apnea by further relaxing the muscles of the upper airway, leading to increased airway collapse during sleep.
Choice B Reason:
CPAP compliance enhances quality of sleep is correct. Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. Compliance with CPAP therapy, meaning consistent and proper use of the CPAP device during sleep, is essential for effectively managing sleep apnea and improving sleep quality.
Choice C Reason:
Alcohol does not affect the risk of obstructive sleep apnea. This statement is incorrect. Alcohol consumption can worsen obstructive sleep apnea by promoting muscle relaxation in the upper airway, leading to increased airway collapse and more frequent episodes of apnea during sleep.
Choice D Reason:
Obesity increases the risk of obstructive sleep apnea. This statement is correct. Obesity is a significant risk factor for obstructive sleep apnea. Excess fat tissue around the neck can increase the likelihood of airway obstruction during sleep, contributing to the development or worsening of sleep apnea.
Choice E Reason:
Positional therapy enhances client comfort is correct. Positional therapy involves strategies to encourage sleeping in positions that minimize the severity of obstructive sleep apnea, particularly for individuals with positional OSA (where apnea events are primarily or significantly worse when sleeping in specific positions, such as supine). This statement is correct.
Choice F Reason:
Smoking increases the risk of obstructive sleep apnea: This statement is correct. Smoking can increase the risk of obstructive sleep apnea due to its effects on upper airway inflammation and respiratory function. Smoking cessation can be beneficial in managing sleep apnea and improving overall health.
Correct Answer is A
Explanation
Choice A Reason:
The client should maintain systolic BP between 120 and 129 mm Hg. This option aligns with current guidelines for blood pressure management following a transient ischemic attack (TIA). Tight blood pressure control is recommended to reduce the risk of recurrent cerebrovascular events, such as stroke. Maintaining systolic blood pressure (SBP) between 120 and 129 mm Hg has been associated with significant risk reduction in stroke recurrence compared to higher blood pressure targets. Therefore, this option reflects the recommended approach for blood pressure management in individuals with a history of TIA.
Choice B Reason:
The client should maintain systolic BP between 136 and 140 mm Hg: This option suggests a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 136 to 140 mm Hg may pose an increased risk of recurrent cerebrovascular events compared to tighter blood pressure control.
Choice C Reason:
The client should maintain systolic BP between 141 and 145 mm Hg. Similarly, this option proposes a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 141 to 145 mm Hg may not provide adequate protection against stroke recurrence compared to tighter blood pressure control.
Choice D Reason:
The client should maintain systolic BP between 130 and 135 mm Hg. While this option suggests a systolic blood pressure (SBP) range that is closer to the recommended target compared to options B and C, it still falls slightly above the optimal range for blood pressure management following a TIA. Tighter blood pressure control, ideally below 130 mm Hg, is typically preferred to reduce the risk of recurrent cerebrovascular events.
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