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
Explanation
Choice A Reason:
"When did you have your last physical?": This question is relevant to assess the client's overall health status and identify any potential comorbidities or health conditions that may be associated with Parkinson's disease. However, it is not as crucial as asking about family history, which directly addresses the client's potential genetic predisposition to Parkinson's disease.
Choice B Reason:
"Do you have any family members with Parkinson's disease?" Parkinson's disease can have both genetic and environmental factors contributing to its development. While the exact cause of Parkinson's disease is not fully understood, having a family history of the condition is a significant risk factor. Individuals with first-degree relatives (parents, siblings, or children) who have Parkinson's disease have an increased risk of developing the condition themselves.
Choice C Reason:
"What kind of work do you do?": This question aims to gather information about the client's occupational history and potential exposure to environmental toxins or factors that may be associated with Parkinson's disease. Certain occupations or exposures to pesticides, herbicides, heavy metals, or other toxins have been linked to an increased risk of Parkinson's disease. While occupational history is important, it is not as directly relevant to assessing the client's risk factors as asking about family history.
Choice D Reason:
"How much coffee do you drink every day?": Research has suggested that caffeine consumption may be associated with a reduced risk of Parkinson's disease or may potentially delay its onset. However, the evidence is not definitive, and the relationship between caffeine intake and Parkinson's disease is still not fully understood. While caffeine consumption may be a relevant factor to explore, especially if the client has a high intake of coffee, it is not as critical as inquiring about family history, which directly addresses genetic predisposition to Parkinson's disease.
Correct Answer is B
Explanation
Choice A Reason:
Prodrome is incorrect. The prodrome phase occurs before the onset of the headache and can last for hours to days. During this phase, individuals may experience subtle changes that serve as warning signs of an impending migraine attack. Common prodromal symptoms include fatigue, mood changes, food cravings, increased thirst, and heightened sensitivity to light or sound. Tingling of the face and blind spots in the eyes are not typically associated with the prodrome phase.
Choice B Reason:
Aura is correct. The aura phase of a migraine typically occurs before or during the headache phase and involves neurological symptoms. Aura symptoms can include visual disturbances such as blind spots, zigzag lines, or flashing lights, as well as sensory symptoms like tingling or numbness, often starting in one part of the body and spreading gradually. The tingling of the face and blind spots in the eyes described by the client are consistent with the aura phase of a migraine.
Choice C Reason:
Postdrome is incorrect. The postdrome phase occurs after the headache phase and can last for hours to days. During this phase, individuals may experience lingering symptoms such as fatigue, difficulty concentrating, mood changes, and muscle aches. While some individuals may experience visual disturbances during the postdrome phase, the tingling of the face and blind spots in the eyes described by the client are more characteristic of the aura phase.
Choice D Reason:
Headache is incorrect. The headache phase of a migraine is characterized by moderate to severe throbbing head pain, often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light or sound. While visual disturbances can occur during the headache phase, the tingling of the face and blind spots in the eyes described by the client precede the onset of headache, suggesting the aura phase rather than the headache phase.
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