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?

Choice A rationale
While emotional disorders and acute pain can occur after a traumatic brain injury (TBI), they are not considered secondary conditions. These are more immediate and direct results of the injury.
Choice B rationale
Loss of sensation and cognition difficulties are common secondary conditions that can develop after a TBI. These can be due to damage to specific areas of the brain during the injury.
Choice C rationale
Body dysmorphia and neurofibrillary tangles are not typically associated with TBI. Body dysmorphia is a psychological disorder, and neurofibrillary tangles are associated with neurodegenerative diseases like Alzheimer’s.
Choice D rationale
Decreased appetite and a lack of sleep can occur after a TBI, but they are more likely to be symptoms rather than secondary conditions. Secondary conditions are typically more long- term and are a result of changes in the brain after the injury.

Choice A rationale: Clients with epilepsy are at high risk of injury from falls during seizures due to sudden loss of consciousness or motor control. Climbing ladders increases the risk of severe trauma, including head injuries and fractures, if a seizure occurs at height. The American Epilepsy Society recommends avoiding elevated surfaces without safety measures. Neurological unpredictability in epilepsy necessitates minimizing exposure to high-risk environments to prevent secondary injuries during seizure episodes.

Choice B rationale: Swimming alone is contraindicated for clients with epilepsy due to the risk of drowning if a seizure occurs in water. A partner can provide immediate assistance, ensuring airway patency and preventing submersion. The CDC and Epilepsy Foundation emphasize supervised aquatic activity. Seizures may cause loss of consciousness or muscle control, making it impossible for the individual to self-rescue. Even brief seizures can lead to aspiration or hypoxic injury if not promptly addressed by a nearby observer.

Choice C rationale: Driving restrictions for clients with epilepsy vary by jurisdiction, but most guidelines, including those from ATI and the Epilepsy Foundation, recommend a seizure-free period of 6 to 12 months before resuming driving. This is based on the risk of sudden incapacitation while operating a vehicle, which endangers both the driver and the public. A 3-month seizure-free period is insufficient and not evidence-based. Neurological stability must be demonstrated over a longer duration to ensure safety.

Choice D rationale: Power tools pose a significant hazard to individuals with epilepsy due to the potential for sudden seizure activity during operation. These tools often involve sharp, fast-moving components that can cause severe injury if control is lost. The Occupational Safety and Health Administration (OSHA) advises against unsupervised use of such equipment by individuals with seizure disorders. Seizure unpredictability necessitates avoiding machinery that requires continuous attention and motor coordination to prevent traumatic injuries.

Choice E rationale: During a seizure, especially a generalized tonic-clonic seizure, it is critical to gently guide the client to the floor to prevent injury from falling. This position helps reduce the risk of head trauma and allows for safer seizure progression. The floor provides a stable surface, minimizing the chance of secondary injury. The nurse should also clear the area of sharp objects and cushion the head to protect the client during convulsions, as recommended by seizure first aid protocols.

Choice F rationale: Positioning a client on their back during postictal recovery is contraindicated due to the risk of airway obstruction. Seizures often result in decreased consciousness, increased oral secretions, or vomiting. The supine position can lead to aspiration or hypoxia. Instead, the recovery position—lying on the side—facilitates drainage of secretions and maintains airway patency. The American Red Cross and Epilepsy Foundation recommend side-lying recovery to reduce respiratory complications and promote safe postictal recovery.