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
Penetrating traumatic brain injuries can cause significant damage to the brain. The extent of this damage is often related to the size, route, and speed of the object entering the brain. A larger, faster object or one that follows a path through vital areas of the brain can cause more severe injury. This is because the object can disrupt normal brain tissue and function, leading to a range of potential effects, from temporary changes in brain function to long-term complications or even death.
Choice B rationale
While it is true that a penetrating injury can cause leakage of cerebrospinal fluid (CSF), this is not the primary source of damage in such injuries. CSF leakage can lead to complications such as meningitis, an infection of the protective membranes covering the brain and spinal cord.
However, the primary damage in penetrating brain injuries comes from the direct physical disruption of brain tissue by the object.
Choice C rationale
Coup and contrecoup injuries are terms used to describe injuries that occur at the site of impact (coup) and on the opposite side of the brain (contrecoup). These injuries are typically associated with blunt force trauma, not penetrating injuries. In a penetrating injury, the damage is localized to the path that the object has taken through the brain, rather than at the point of impact and its opposite side.

Choice D rationale
While a penetrating object can indeed shatter the skull and potentially cause an infection, the primary damage in penetrating brain injuries is caused by the direct injury to the brain tissue itself. Infections are a secondary complication that can occur if bacteria enter the brain through the wound.

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?

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