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","C","D","E"]
Explanation
Choice A rationale
Decreased visual acuity can increase the risk of falls, which are a common cause of head injuries in older adults. Impaired vision can affect balance and coordination, making it more difficult for an individual to navigate their environment safely.
Choice B rationale
While motor vehicle crashes can certainly lead to head injuries, they are not one of the most common causes of head injuries in older adults. Falls are actually the leading cause of head injuries in this population.
Choice C rationale
Polypharmacy, or the use of multiple medications by a patient, is common in older adults and can increase the risk of falls and, consequently, head injuries. Certain medications can cause side effects such as dizziness or confusion, which can lead to falls.
Choice D rationale
Weakness, particularly in the lower body, can increase the risk of falls and subsequent head injuries in older adults. Lower body weakness can affect an individual’s balance and mobility, making falls more likely.
Choice E rationale
Chronic hypertension can lead to a variety of health complications, including an increased risk of falls and head injuries. Hypertension can cause dizziness and balance problems, which can increase the risk of falls.
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.
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