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 D

Explanation

Choice A rationale
While a CT angiogram can indeed reveal fractures within the skull or spine, this is not its primary purpose in the context of a subarachnoid hemorrhage. The main goal is to visualize the blood vessels in the brain.
Choice B rationale
A CT angiogram does not primarily reveal overproduction of cerebrospinal fluid (CSF). It is used to visualize the blood vessels in the brain.
Choice C rationale
While a CT angiogram can show areas of edema within the brain tissue, this is not its main purpose in the context of a subarachnoid hemorrhage. The primary goal is to visualize the blood vessels in the brain.

Choice D rationale
A CT angiogram can indeed reveal decreased blood flow related to vasospasm in the context of a subarachnoid hemorrhage. Vasospasm is a condition in which blood vessels spasm, leading to vasoconstriction. This can reduce blood flow to the brain, which can be visualized on a CT angiogram.

A. The client should maintain systolic BP between 141 and 145 mm Hg B. The client should maintain systolic BP between 120 and 129 mm Hg C. The client should maintain systolic BP between 130 and 135 mm Hg D. The client should maintain systolic BP between 136 and 140 mm Hg .

Correct Answer is B

Explanation

Choice A rationale
Maintaining systolic BP between 141 and 145 mm Hg is considered high and can increase the risk of stroke.
Choice B rationale

The client should maintain systolic BP between 120 and 129 mm Hg. This is considered a normal blood pressure range and can help reduce the risk of stroke.
Choice C rationale
Maintaining systolic BP between 130 and 135 mm Hg is considered elevated and can increase the risk of stroke.
Choice D rationale
Maintaining systolic BP between 136 and 140 mm Hg is considered high and can increase the risk of stroke.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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