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

Explanation

Choice A rationale

Cognitive behavioral therapy (CBT) is a type of psychological treatment that can be effective for a range of conditions, including chronic pain. However, it may not be the most suitable for acute pain management at home following a knee injury. CBT usually involves working with a trained therapist over multiple sessions, which may not be practical or immediately beneficial in this context.
Choice B rationale
Intermittent ice compress is a highly recommended non-pharmacological method for managing acute pain, especially following a knee injury. The cold temperature from the ice can help numb the area, reducing pain and inflammation. It’s a simple, cost-effective, and readily available method that can be easily applied at home.
Choice C rationale
Phototherapy, also known as light therapy, involves exposure to specific wavelengths of light using polychromatic polarised light, lasers, light-emitting diodes, fluorescent lamps, or dichroic lamps. While it has been used to treat conditions like seasonal affective disorder, skin conditions, and neonatal jaundice, its effectiveness in managing acute pain following a knee injury is not well-established.
Choice D rationale
Walking on a treadmill might not be suitable for a patient experiencing acute pain following a knee injury. Physical activity is generally beneficial for overall health and certain types of chronic pain. However, in the case of an acute knee injury, rest and immobilization are often recommended initially to allow the injured tissues to heal.

A. Client’s age B. History of sickle cell disease C. Parent who has cardiovascular disease D. Hypertension

Correct Answer is D

Explanation

Choice A rationale
Age is a non-modifiable risk factor for stroke. As people age, their risk of stroke increases. However, this is not something that can be changed or controlled.
Choice B rationale
Sickle cell disease is a genetic disorder that can increase the risk of stroke, particularly in children. However, it is not a modifiable risk factor because it is determined by the person’s genes.
Choice C rationale
Having a parent with cardiovascular disease can increase a person’s risk of stroke. However, this is a non-modifiable risk factor because it is determined by genetics.
Choice D rationale
Hypertension, or high blood pressure, is a major modifiable risk factor for stroke. It can be controlled through lifestyle changes and medication.

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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 B

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