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 ["B","C","D"]

Explanation

Choice A rationale
Hyponatremia, or low sodium levels, is not typically a symptom of degenerative disc disease. It can be caused by a variety of conditions, but it is not directly linked to degenerative disc disease.
Choice B rationale
Paresthesia, or abnormal sensations such as tingling or prickling, can develop with degenerative disc disease. This is due to the fact that degenerative changes can lead to nerve compression, which can cause these sensations.
Choice C rationale
Foot drop, a gait abnormality, can be a symptom of degenerative disc disease. It can occur if the disease process affects the nerves that control the muscles involved in lifting the foot.
Choice D rationale
Intermittent pain is a common symptom of degenerative disc disease. The pain can vary in intensity and may be worse with certain activities or positions.
Choice E rationale
Hyperreflexia, or overactive reflexes, is not typically a symptom of degenerative disc disease. It is more commonly associated with conditions that affect the upper motor neurons.

A. Assessing muscle strength B. Checking for facial symmetry C. Checking peripheral pulses D. Evaluating vision changes E. Checking for aphasia F. Asking about smoking history

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale
Assessing muscle strength is important after a fall as it can help determine if the fall was due to muscle weakness or other neurological issues.
Choice B rationale
Checking for facial symmetry is crucial as asymmetry may indicate a stroke or other serious neurological condition.
Choice C rationale
While checking peripheral pulses is important in general, it may not be the top priority in this case unless there is a specific reason to suspect circulatory issues.
Choice D rationale
Evaluating vision changes is important as sudden vision loss or changes could indicate a serious condition such as a stroke.
Choice E rationale
Checking for aphasia, or difficulty with language, is crucial as it can be a sign of a stroke or other serious neurological condition.
Choice F rationale
Asking about smoking history may not be a priority in the immediate assessment of a patient who has just fallen.

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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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