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. The patient reports a burning sensation. B. The patient grimaces when they move. C. The patient rates their pain as an 8 on a scale of 0 to 10. D. The patient states the pain is located in their abdomen.

Correct Answer is B

Explanation

Choice A rationale
A patient reporting a burning sensation is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice B rationale
A patient grimacing when they move is an objective sign of pain. It is observable and does not rely on the patient’s verbal report.
Choice C rationale

A patient rating their pain as an 8 on a scale of 0 to 10 is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice D rationale
A patient stating the pain is located in their abdomen is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.

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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

A nurse is caring for a patient experiencing acute pain following a knee injury. The nurse is educating the patient about pain management strategies to use at home.Which of the following non-pharmacological methods of pain relief should the nurse include in their teaching?

Correct Answer is B

Explanation

A nurse is evaluating a patient for signs of pain. Which of the following is an objective sign of pain?

Correct Answer is B

Explanation

A nurse is educating a student about cerebral edema. The student nurse inquires, “What type of cerebral edema is associated with a patient who has had a stroke?” Which of the following is the best response from the nurse?

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A nurse is caring for a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will maintain cerebral perfusion pressure constant?

A nurse is providing care for a patient in the emergency department who has been preliminarily diagnosed with a transient ischemic attack (TIA). Which diagnostic test should the nurse expect the healthcare provider to order?

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?

A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?