A nurse is providing care for a patient who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?

Maintain the head of the bed between 30 and 45 degrees.

Administer hypotonic intravenous solutions.

Keep lights turned to medium level in the evening.

Reposition the patient every shift.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Maintaining the head of the bed between 30 and 45 degrees is a common intervention for a patient at risk of cerebral aneurysm rupture. This position can help reduce intracranial pressure and promote venous drainage from the brain.
Choice B rationale
Administering hypotonic intravenous solutions is not typically recommended for patients at risk of cerebral aneurysm rupture. Hypotonic solutions can lead to cerebral edema, which can increase intracranial pressure and potentially contribute to aneurysm rupture.
Choice C rationale
Keeping lights at a medium level in the evening is not a specific intervention for patients at risk of cerebral aneurysm rupture. While maintaining a comfortable and restful environment is important, there’s no evidence to suggest that the level of lighting has a direct impact on the risk of aneurysm rupture.
Choice D rationale
Repositioning the patient every shift is a standard nursing intervention to prevent pressure ulcers and promote comfort. However, it is not a specific intervention for patients at risk of cerebral aneurysm rupture.

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Correct Answer is D

Explanation

Choice A rationale
While a CT angiogram can indeed reveal fractures within the skull or spine, this is not its primary purpose in the context of a subarachnoid hemorrhage. The main goal is to visualize the blood vessels in the brain.
Choice B rationale
A CT angiogram does not primarily reveal overproduction of cerebrospinal fluid (CSF). It is used to visualize the blood vessels in the brain.
Choice C rationale
While a CT angiogram can show areas of edema within the brain tissue, this is not its main purpose in the context of a subarachnoid hemorrhage. The primary goal is to visualize the blood vessels in the brain.

Choice D rationale
A CT angiogram can indeed reveal decreased blood flow related to vasospasm in the context of a subarachnoid hemorrhage. Vasospasm is a condition in which blood vessels spasm, leading to vasoconstriction. This can reduce blood flow to the brain, which can be visualized on a CT angiogram.

A. Pupillary dilation B. Persistent headache C. Presence of hand tremors D. Difficulty waking E. Foot drop

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

Explanation

Choice A rationale
Pupillary dilation can be a sign of increased intracranial pressure, which could be a result of a traumatic brain injury following a motor vehicle accident. It’s important to assess for this symptom as it may indicate a serious condition that requires immediate medical attention.
Choice B rationale
Persistent headache is a common symptom following a head injury and can be a sign of a concussion or more serious brain injury. It’s crucial to monitor for this symptom as it can provide important information about the patient’s condition.
Choice C rationale
Presence of hand tremors is not typically associated with a head injury from a motor vehicle accident. While tremors can be a symptom of various neurological conditions, they are not commonly seen immediately after a traumatic head injury.
Choice D rationale

Difficulty waking can be a sign of a serious head injury. It could indicate a concussion or other type of traumatic brain injury. This symptom should be closely monitored as it may require immediate medical intervention.
Choice E rationale
Foot drop is not typically a symptom observed immediately after a motor vehicle accident. It’s more commonly associated with peripheral nerve conditions or stroke, rather than a head injury.

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A nurse is providing care for a patient 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 caring for a client who has a subarachnoid hemorrhage and asks why they are having a CT angiography. Which of the following should the nurse understand about CT angiography?

Correct Answer is D

Explanation

A nurse is caring for a patient who was involved in a motor vehicle accident.The patient is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional symptoms should the nurse assess the patient for? (Select All that Apply.)

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

Explanation

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