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 A

Explanation

Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale

While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.

A. Computerized Tomography Angiography (CTA) B. Transesophageal Echocardiogram (TEE) C. Complete Blood Count (CBC) D. Prothrombin Time (PT) .

Correct Answer is A

Explanation

Choice A rationale
A Computerized Tomography Angiography (CTA) scan is often used to diagnose a Transient Ischemic Attack (TIA). This imaging test can provide detailed images of blood vessels in the brain and neck, allowing healthcare providers to identify blockages or other abnormalities that could have caused the TIA12.
Choice B rationale
A Transesophageal Echocardiogram (TEE) is a type of echocardiogram that uses a probe passed down the esophagus to obtain detailed images of the heart. While it can be useful in diagnosing certain heart conditions, it is not typically the first-line diagnostic test for a TIA12.
Choice C rationale
A Complete Blood Count (CBC) is a blood test that measures different components of the blood, including red and white blood cells and platelets. While it can provide useful information about a person’s overall health, it is not typically used to diagnose a TIA12.
Choice D rationale
Prothrombin Time (PT) is a blood test that measures how long it takes for your blood to clot. While it can provide information about clotting disorders, it is not typically used to diagnose a

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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

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Correct Answer is A

Explanation

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Correct Answer is A

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