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.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hyperoxia, or high oxygen levels, can cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated. Too much oxygen can lead to oxygen toxicity and cause damage to the lungs and other organs, including the brain.
Choice B rationale
A platelet count of 250,000/mm^3 is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice C rationale
A hemoglobin level of 16 g/dL is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice D rationale
A Glasgow Coma Scale score of 16 is not possible as the maximum score is 15. A higher score indicates a less severe injury, so it would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Correct Answer is C
Explanation
Choice A rationale
Smoking is a risk factor for many health conditions, including headaches. However, it is not a common precipitating factor in both tension-type and cluster headaches.
Choice B rationale
Depression can be associated with both tension-type and cluster headaches, but it is not a common precipitating factor for these types of headaches.
Choice C rationale
Stress is a common precipitating factor for both tension-type and cluster headaches. Both types of headaches can be triggered by psychological factors like stress.
Choice D rationale
Poor posture can contribute to tension-type headaches by causing muscle tension in the neck and shoulders. However, it is not a common precipitating factor for cluster headaches.
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