A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Limit the client's ambulation to once a day.

Place the client in protective isolation.

Minimize environmental stimuli.

Elevate the head of the client's bed 45 degrees.

Answer and Explanation

The Correct Answer is C

A. Limiting ambulation is not a standard aneurysm precaution. While excessive activity should be avoided, strict bed rest is not always required unless specifically prescribed.
B. Protective isolation is not necessary for a client with an intracranial aneurysm, as the condition is not related to infection or immune suppression.
C. Minimizing environmental stimuli is essential to reduce stress, prevent increases in blood pressure, and decrease the risk of aneurysm rupture. A quiet, calm environment helps prevent sudden changes in intracranial pressure.
D. Elevating the head of the bed to 45 degrees may increase intracranial pressure. A more appropriate position is keeping the head of the bed elevated at 30 degrees to promote venous drainage while preventing excessive pressure on the aneurysm.

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Correct Answer is B

Explanation

A. Observe the client's ability to smile and frown: This assessment is related to cranial nerve VII (facial nerve), which controls facial expressions.
B. Instruct the client to look up and down without moving his head: Cranial nerve III (oculomotor nerve) controls eye movements, including upward and downward gaze. Asking the client to look up and down without moving the head assesses the function of this nerve.

C. Ask the client to shrug his shoulders against passive resistance: This assessment is related to cranial nerve XI (accessory nerve), which innervates the trapezius and sternocleidomastoid muscles involved in shoulder shrugging.

D. Have the client stand with eyes his closed and touch his nose: This assessment is part of the cerebellar function test and assesses coordination and proprioception but does not specifically assess cranial nerve III.

A. Catheterize for residual urine after voiding. B. Instruct the patient how to self-catheterize. C. Assist the patient to the toilet every 2 hours. D. Teach the patient to use the Credé method.

Correct Answer is B

Explanation

A. Catheterize for residual urine after voiding: While catheterization for residual urine may be necessary in some cases, it is not the most appropriate long-term solution for managing a neurogenic reflexic bladder. It does not promote patient independence or long-term bladder health.

B. Instruct the patient how to self-catheterize: Self-catheterization empowers the patient to manage their bladder function independently and reduces the risk of urinary tract infections
associated with indwelling catheters. It is the preferred method for managing neurogenic bladder in patients with spinal cord injury.

C. Assist the patient to the toilet every 2 hours: While assisting the patient to the toilet at regular intervals may help prevent urinary accidents, it does not address the underlying issue of neurogenic bladder or promote long-term bladder management.

D. Teach the patient to use the Credé method: The Credé method involves applying manual pressure to the bladder to promote voiding. While it may be used in some situations, it is not the preferred method for managing neurogenic bladder, especially in patients with spinal cord injury.

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