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
Explanation
Choice A Reason:
Flying itself is not typically considered a factor that worsens MS manifestations. However, factors related to flying, such as stress, fatigue, changes in routine, and potential exposure to infections, may contribute to symptom exacerbation in some individuals with MS.
Choice B Reason:
Sunbathing is appropriate. Exposure to excessive heat, such as sunbathing or prolonged exposure to hot weather, can lead to temporary worsening of MS symptoms, a phenomenon known as Uhthoff's phenomenon. Increased body temperature can temporarily impair nerve conduction in individuals with MS, resulting in exacerbation of symptoms such as fatigue, weakness, sensory disturbances, and cognitive impairment.
Choice C Reason:
Working in an office is inappropriate. Working in an office environment is not inherently associated with exacerbation of MS manifestations. However, factors such as stress, fatigue, poor ergonomic conditions, and limited mobility during prolonged periods of sitting may contribute to symptom exacerbation in some individuals with MS.
Choice D Reason:
High altitude travel is inappropriate. High altitude travel can exacerbate MS symptoms due to the decreased oxygen levels and potential changes in barometric pressure at high altitudes. Hypoxia (low oxygen levels) at high altitudes may exacerbate fatigue, weakness, and cognitive impairment in individuals with MS. Changes in barometric pressure can also trigger or worsen symptoms such as headaches, sensory disturbances, and balance problems in some individuals with MS.
Correct Answer is D
Explanation
Correct answer: D
Choice A Reason:
Decreased pulmonary vascular resistance is incorrect. Inflammatory mediators released in response to a pulmonary embolism can lead to vasoconstriction and increased pulmonary vascular resistance. This is part of the body's response to redirect blood flow away from the affected area of the lung and maintain adequate perfusion to other areas.
Choice B Reason:
Hypercapnia is incorrect. Hypercapnia refers to elevated levels of carbon dioxide (CO2) in the blood.Hypocapnia usually is present with embolism; hypercapnia, on the other hand, is rare.
Choice C Reason:
Hypoventilation is incorrect. Hypoventilation occurs when there is inadequate ventilation of the lungs relative to metabolic demands. In the context of a pulmonary embolism, hypoventilation can occur due to factors such as pain, respiratory muscle fatigue, or impaired gas exchange, all of which can be influenced by the release of inflammatory mediators.
Choice D Reason:
Respiratory alkalosis is correct.In response to the blockage and the resulting inflammation, the body often increases the respiratory rate as a compensatory mechanism to maintain adequate oxygen levels and remove carbon dioxide.Due to the increased breathing rate, there is excessive exhalation of carbon dioxide, leading to a decrease in the partial pressure of CO2 in the blood. This results in an increase in blood pH, causing respiratory alkalosis.
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