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 B
Explanation
Choice A Reason:
Higher oxygen saturations of 98% to 99% is inappropriate. A pneumothorax involves the presence of air in the pleural space, which can compromise lung function and gas exchange. This compromised lung function typically leads to decreased oxygenation of the blood, resulting in lower oxygen saturations rather than higher saturations.
Choice B Reason:
Lower oxygen saturations of 93% to 94% is appropriate. A pneumothorax disrupts the normal exchange of oxygen and carbon dioxide in the lungs due to partial or complete lung collapse. As a result, the affected lung is unable to adequately oxygenate the blood, leading to lower oxygen saturations, which are indicative of hypoxemia.
Choice C Reason:
Lower energy expenditure is inappropriate. Energy expenditure is not typically affected by a pneumothorax. While the discomfort and respiratory distress associated with a pneumothorax may cause the individual to limit physical activity, there is no direct impact on overall energy expenditure.
Choice D Reason:
Increased lung capacity is inappropriate. A pneumothorax results in partial or complete collapse of the affected lung, reducing lung capacity rather than increasing it. The presence of air in the pleural space creates positive pressure, which can compress the lung and decrease its ability to expand fully during inhalation.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Take small bites of food is correct. Taking small bites of food can help prevent choking and aspiration, particularly during mealtime. It is a recommended practice for individuals with epilepsy to reduce the risk of aspiration if a seizure were to occur during eating.
Choice B Reason:
Liquids should be thickened is incorrect. Thickened liquids are typically recommended for individuals with swallowing difficulties (dysphagia) to help prevent aspiration. However, thickened liquids may not be necessary for all individuals with epilepsy unless specifically indicated based on their swallowing function assessment.
Choice C Reason:
Eat sitting slightly forward correct.: Eating while sitting slightly forward can help prevent aspiration in case of a seizure during meals. This position allows gravity to assist in preventing food or liquid from entering the airway.
Choice D Reason:
Chew food thoroughly before swallowing is correct. Thoroughly chewing food before swallowing is important for proper digestion and to reduce the risk of choking or aspiration, especially for individuals with epilepsy who may be at increased risk of aspiration during a seizure.
Choice E Reason:
Avoid having conversations while eating is incorrect. Avoiding conversations while eating is not directly related to epilepsy management. However, focusing on eating and taking appropriate precautions, such as sitting upright and chewing food thoroughly, can help reduce the risk of aspiration during meals.
Choice F Reason:
Avoid fiber in the diet is incorrect.: There is no specific recommendation to avoid fiber in the diet for individuals with epilepsy. In fact, a balanced diet that includes fiber-rich foods can promote overall health and well-being, which is important for individuals with epilepsy as well.
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