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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Drooling is inappropriate. Drooling, also known as sialorrhea, is a common symptom in Parkinson's disease due to impaired swallowing and reduced control of the muscles involved in saliva production. Anticholinergic medications can exacerbate dry mouth, which may contribute to drooling. However, drooling is not typically a side effect that would be specifically associated with anticholinergic use.

Choice B Reason:

Anhidrosis is appropriate. Anhidrosis refers to the inability to sweat normally. Anticholinergic medications can inhibit sweating by blocking the action of acetylcholine on sweat glands, leading to decreased sweating and potentially causing hyperthermia. Anhidrosis is a potential side effect of anticholinergic agents and should be reported to the healthcare provider due to the risk of overheating.

Choice C Reason:

Tremors is inappropriate. Tremors are a common symptom of Parkinson's disease and are typically not caused by anticholinergic medications. In fact, anticholinergic agents are often prescribed to help reduce tremors in individuals with Parkinson's disease. Tremors would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.

Choice D Reason:

Rigidity is inappropriate. Rigidity, or stiffness of the muscles, is a characteristic symptom of Parkinson's disease resulting from the loss of dopamine-producing neurons in the brain. While anticholinergic medications can help alleviate some symptoms of Parkinson's disease, they are not typically associated with rigidity. Rigidity would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.

A. Weight control if the client's BMI is greater than 35 B. Healthy lifestyle C. Smoking cessation D. Heart disease prevention E. Glycemic control if the client is diabetic

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Reason:

Weight control if the client's BMI is greater than 35 is correct. Obesity is a risk factor for cardiovascular disease and can exacerbate symptoms of heart failure. Weight control, particularly if the client's BMI is greater than 35, is important for managing cardiac conditions such as heart failure and reducing the risk of pulmonary edema.

Choice B Reason:

Healthy lifestyle is correct. Adopting a healthy lifestyle, including regular exercise, balanced diet, adequate hydration, and stress management, is essential for managing cardiac conditions and reducing the risk of complications such as pulmonary edema.

Choice C Reason:

Smoking cessation is correct. Smoking is a major risk factor for cardiovascular disease and can worsen heart failure symptoms. Smoking cessation is crucial for managing cardiac conditions and reducing the risk of pulmonary edema and other complications.

Choice D Reason:

Heart disease prevention is correct. Providing information about heart disease prevention strategies, such as maintaining a healthy diet, managing blood pressure and cholesterol levels, regular exercise, and regular medical check-ups, can help reduce the risk of exacerbations and complications in clients with pre-existing cardiac conditions.

Choice E Reason:

Glycemic control if the client is diabetic is correct. Diabetes is a risk factor for cardiovascular disease and can contribute to the development and progression of heart failure. Glycemic control, along with lifestyle modifications and medication management, is important for managing diabetes and reducing the risk of complications such as pulmonary edema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing discharge medications with a client who has Parkinson's disease. The nurse should include teaching about the client's anticholinergic agent. Which of the following side effects should the nurse advise the client to report?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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