A nurse is caring for a client who has chronic migraine headaches. The client asks the nurse if it could be a cerebral aneurysm. Which of the follow responses should the nurse use?
"If you have a cerebral aneurysm, you would be having seizures."
"If you have a cerebral aneurysm, you will experience nausea and vomiting."
"If you had a cerebral aneurysm, you would have a stiff neck."
"If you have a cerebral aneurysm, you typically will have no symptoms."
The Correct Answer is D
"If you have a cerebral aneurysm, you would be having seizures. “is incorrect because not all cerebral aneurysms cause seizures. Seizures may occur if the aneurysm ruptures and causes bleeding into the brain, but they are not a universal symptom of an unruptured cerebral aneurysm.
Choice B Reason:
"If you have a cerebral aneurysm, you will experience nausea and vomiting. “is incorrect because while headaches, nausea, and vomiting can occur with a ruptured cerebral aneurysm (subarachnoid hemorrhage), they are not necessarily present in all cases, especially with unruptured aneurysms.
Choice C Reason:
"If you had a cerebral aneurysm, you would have a stiff neck." is incorrect because a stiff neck (meningeal irritation) is typically associated with subarachnoid hemorrhage from a ruptured cerebral aneurysm, but it is not always present and is not a definitive symptom of an unruptured aneurysm.
Choice D Reason:
"If you have a cerebral aneurysm, you typically will have no symptoms." Cerebral aneurysms can vary greatly in terms of their presentation and symptoms. While some aneurysms may cause symptoms such as headaches, nausea, vomiting, seizures, or a stiff neck, many cerebral aneurysms are asymptomatic and go unnoticed until they rupture or are incidentally discovered during imaging studies for other reasons.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason:
The client admitted with diabetic ketoacidosis (DKA) is correct. Diabetes is a common cause of peripheral neuropathy, particularly if poorly controlled. Diabetic ketoacidosis (DKA) is a severe complication of diabetes characterized by high blood sugar levels and ketone accumulation. Prolonged uncontrolled diabetes can lead to nerve damage and peripheral neuropathy.
Choice B Reason:
The client admitted with sleep apnea is incorrect. Sleep apnea is a sleep disorder characterized by pauses in breathing or shallow breathing during sleep. While sleep apnea itself is not typically associated with peripheral neuropathy, underlying conditions such as obesity or diabetes, which are risk factors for sleep apnea, can also increase the risk of peripheral neuropathy.
Choice C Reason:
The client admitted with a hypertensive crisis is incorrect. Hypertension (high blood pressure) is not directly associated with peripheral neuropathy. However, poorly controlled hypertension can lead to vascular complications and contribute to conditions such as atherosclerosis, which may indirectly increase the risk of peripheral neuropathy.
Choice D Reason:
The client admitted for an exacerbation of Systemic Lupus Erythematosus (SLE) is correct. Systemic Lupus Erythematosus (SLE) is an autoimmune disease that can affect various organs and tissues, including the peripheral nerves. Peripheral neuropathy can occur as a complication of SLE, particularly in cases of active disease or as a result of certain medications used to treat SLE.
Choice E Reason:
The client admitted with untreated tuberculosis is incorrect. Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis. While TB itself is not typically associated with peripheral neuropathy, certain medications used to treat TB, such as isoniazid, can cause peripheral neuropathy as a side effect.
Choice F Reason:
The client admitted with cirrhosis secondary to chronic alcohol use is correct. Chronic alcohol use and cirrhosis can lead to various neurological complications, including peripheral neuropathy. Alcohol-related peripheral neuropathy often presents with sensory symptoms such as tingling, numbness, and pain in the extremities.
Correct Answer is D
Explanation
Choice A Reason:
Hypoxemia due to dead space is not appropriate. Dead space refers to areas of the lung where ventilation occurs but no perfusion takes place. In ARDS, hypoxemia typically occurs due to ventilation-perfusion (V/Q) mismatch and shunting rather than dead space.
Choice B Reason:
Impaired carbon dioxide elimination due to shunting is not appropriate. Shunting occurs when blood bypasses ventilated alveoli, leading to inadequate gas exchange. In ARDS, shunting contributes to hypoxemia, but it doesn't directly impair carbon dioxide elimination.
Choice C Reason:
Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is incorrect. V/Q mismatch occurs when ventilation and perfusion are mismatched in different areas of the lung. This leads to areas of low ventilation (dead space) and areas of low perfusion (shunting). V/Q mismatch contributes to hypoxemia in ARDS but does not typically lead to decreased pulmonary arterial pressure.
Choice D Reason:
Decreased pulmonary compliance due to stiffness is correct. This is a characteristic feature of ARDS. The inflammation and damage to the alveoli cause them to become stiff, reducing pulmonary compliance and impairing lung expansion during ventilation.
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