A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?
Keep lights turned to medium level in the evening.
Maintain the head of the bed between 30 and 45°.
Administer hypotonic intravenous solutions.
Reposition the client every shift.
The Correct Answer is B
Choice A Reason:
Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.
Choice B Reason:
Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.
Choice C Reason:
Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.
Choice D Reason:
Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A Reason:
Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood and is not typically associated with degenerative disc disease. This finding is unrelated to the pathophysiology of DDD.
Choice B Reason:
Paresthesia is correct. Yes, paresthesia, which refers to abnormal sensations such as tingling, numbness, or burning, can develop with degenerative disc disease. Nerve compression or irritation due to disc degeneration can lead to paresthesia in the affected area, typically radiating along the nerve pathway.
Choice B Reason:
Foot drop is correct. Yes, foot drop can develop with degenerative disc disease, especially if the condition leads to nerve compression or damage in the lumbar spine (lower back). Foot drop refers to difficulty lifting the front part of the foot due to weakness or paralysis of the muscles involved in dorsiflexion.
Choice D Reason:
Intermittent pain is correct. Yes, intermittent pain is a hallmark symptom of degenerative disc disease. Pain may vary in intensity and may worsen with certain movements or activities. Individuals with DDD may experience episodes of acute pain, as well as chronic, persistent discomfort.
Correct Answer is D
Explanation
"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.
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