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 D

Explanation

- A) Extension of the arms is incorrect because decorticate posturing is characterized by flexion into the body, not extension away from it.
- B) External rotation of the lower extremities is not associated with decorticate posturing, which involves movements primarily of the upper extremities.
- C) Pronation of the hands is incorrect as decorticate posturing typically involves flexion of the arms, wrists, and fingers into the chest.
- D) Plantar flexion of the legs is correct because decorticate posturing includes internal rotation and flexion of the arms and wrists, with the legs extended and feet plantar flexed.

A. The patient reports having a stiff neck. B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). C. The patient reports a severe and unrelenting headache. D. The patient's blood pressure (BP) is 90/50 mm Hg

Correct Answer is D

Explanation

A. The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.

B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.

C. The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.

D. The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Correct Answer is D

Explanation

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Correct Answer is D

Explanation

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