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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Providing nonpharmacological pain interventions to each client equally is an example of justice, not autonomy. Justice in healthcare refers to treating all patients fairly and equitably.
Choice B rationale
Fulfilling a promise to a client that they will return with their pain medication is an example of fidelity, not autonomy. Fidelity refers to being faithful to commitments and promises.
Choice C rationale
Administering a scheduled pain medication for a client who is having pain is an example of beneficence, not autonomy. Beneficence refers to taking actions that are of benefit to the patient.
Choice D rationale
Giving a client the choice of when to take a pain medication is an example of autonomy. Autonomy in healthcare refers to the patient’s right to make decisions about their own care.
Correct Answer is D
Explanation
Choice A rationale
Monitoring volume status is important in managing increased ICP, but it is not a direct intervention to reduce ICP78.
Choice B rationale
Ensuring proper ventriculostomy transducer levels is important in monitoring ICP, but it is not a direct intervention to reduce ICP78.
Choice C rationale
Managing sedation can help control agitation and excessive muscular activity, which can potentially increase ICP. However, it is not a direct intervention to reduce ICP78.
Choice D rationale
Elevating the head of the bed 15 degrees can help promote venous drainage, enhance cerebral perfusion, and reduce ICP78.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.