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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.
B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.
C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.
D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.
Correct Answer is D
Explanation
A. Obtain the client's heart rate: While obtaining the client's heart rate is important in the assessment of autonomic dysreflexia, assessing for and addressing the underlying cause take precedence.
B. Administer a nitrate antihypertensive: Administering antihypertensive medication may be necessary if autonomic dysreflexia is confirmed, but it is not the first action to take. Addressing the cause of autonomic dysreflexia, such as bladder distention, is the priority.
C. Place the client in a high-Fowler's position: Elevating the client's head may help reduce blood pressure, but it does not address the underlying cause of autonomic dysreflexia. Assessing for and addressing the cause, such as bladder distention, is the priority.
D. Assess the client for bladder distention: Autonomic dysreflexia is commonly triggered by stimuli below the level of spinal cord injury, such as bladder distention. Assessing the client's bladder for distention and addressing any urinary retention or obstruction is the first action to take in managing autonomic dysreflexia.
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