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 D

Explanation

Choice A Reason:

Depression is incorrect. While depression can contribute to headaches in some individuals, it is more commonly associated with migraine headaches rather than tension-type headaches or cluster headaches. People with depression may experience changes in neurotransmitter levels and alterations in pain perception, which can exacerbate migraines. However, tension-type headaches and cluster headaches are generally less strongly associated with depression as a precipitating factor compared to migraines.

Choice B Reason:

Smoking is incorrect. Smoking can be a trigger for headaches in some individuals, particularly migraines, due to the vasoconstrictive effects of nicotine and other compounds in tobacco smoke. However, smoking is not universally recognized as a common precipitating factor for tension-type headaches or cluster headaches. While individuals with cluster headaches may have higher rates of smoking compared to the general population, it is not a factor commonly shared with tension-type headaches.

Choice C Reason:

Poor posture is incorrect. Poor posture can contribute to muscle tension and cervical spine strain, which may trigger tension-type headaches. However, poor posture is not typically considered a precipitating factor specific to cluster headaches. While tension-type headaches may be exacerbated by poor posture, cluster headaches are characterized by severe, unilateral pain typically centered around the eye or temple, with associated autonomic symptoms such as tearing, nasal congestion, or ptosis.

Choice D Reason:

Stress is correct. Stress is a well-established precipitating factor for both tension-type headaches and cluster headaches. Stress can lead to muscle tension and contraction, which are common triggers for tension-type headaches. Additionally, stress can also contribute to the onset or worsening of cluster headaches, although the exact mechanisms underlying this association are not fully understood. Therefore, stress is a common precipitating factor for both tension-type headaches and cluster headaches.

A. Osteoporosis B. Polyuria C. Anxiety and depression D. Delirium

Correct Answer is D

Explanation

Choice A Reason:

Osteoporosis is inappropriate. Chronic respiratory acidosis can lead to osteoporosis over time due to several factors, including chronic hypoxemia, which can affect bone metabolism and lead to bone loss.

Choice B Reason:

Polyuria is inappropriate. Polyuria, or increased urination, is not typically associated with chronic respiratory acidosis. In fact, respiratory acidosis tends to cause retention of bicarbonate ions, which can lead to compensatory metabolic alkalosis and decreased urine output.

Choice C Reason:

Anxiety and depression is inappropriate. Chronic respiratory acidosis can lead to symptoms such as lethargy, confusion, and decreased mental acuity due to the effects of elevated CO2 levels on the central nervous system. While anxiety and depression are not direct consequences of chronic respiratory acidosis, individuals with COPD may experience anxiety and depression as a result of their chronic respiratory condition.

Choice D Reason:

Delirium is correct. Delirium, characterized by an acute change in mental status, confusion, and altered consciousness, can occur in severe cases of chronic respiratory acidosis, especially during acute exacerbations. Elevated CO2 levels can affect brain function and lead to symptoms of delirium.

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