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 C
Explanation
Choice A rationale
Nicardipine is a calcium channel blocker used to treat high blood pressure. While it can be used in the management of subarachnoid hemorrhage, it is not primarily used to decrease intracranial pressure.
Choice B rationale
Dopamine is a type of medication used to treat certain conditions such as low blood pressure, heart failure, and Parkinson’s disease. It is not typically used to decrease intracranial pressure in the context of a subarachnoid hemorrhage.
Choice C rationale
Mannitol is a type of medication that is used to decrease intracranial pressure. It works by drawing fluid out of the brain to help reduce swelling.
Choice D rationale
Phenytoin is a medication used to control seizures. While it can be used in the management of subarachnoid hemorrhage, it is not primarily used to decrease intracranial pressure. Migraine Explore
Correct Answer is C
Explanation
Choice A rationale
While improved rehabilitation outcomes and temporary behavior changes can occur after a neurological injury, they are not typically considered psychosocial changes. Psychosocial changes often involve alterations in the way individuals perceive, interact with, and navigate their social environments.
Choice B rationale
Improved mood stability and temper control are not typically associated with the aftermath of a neurological injury. In fact, individuals may experience mood swings, irritability, and difficulties with emotional regulation.
Choice C rationale
Changes to social cognition and challenges to inhibitory control are indeed possible psychosocial changes a client might have after sustaining a neurological injury. Social cognition involves understanding and interpreting social cues, which can be affected by brain injury.
Challenges to inhibitory control can lead to impulsive behavior and difficulties in social situations.
Choice D rationale
While a sense of purpose, improved motivation, and stable relationships can be part of a successful recovery process, they are not typically direct outcomes of a neurological injury. In
fact, relationships may be strained and motivation can be affected due to the physical and emotional challenges associated with such an injury.
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