A client has just been diagnosed with an aneurysm. When planning discharge teaching for this client, what instructions should the nurse provide to the client?
Take an herbal form of feverfew
Take opioid analgesics
Avoid heavy lifting
Include peanut butter, bread, or tart foods in the diet
The Correct Answer is C
Reasoning:
Choice A reason: Feverfew, an herbal supplement, is sometimes used for migraines but has no proven role in aneurysm management. It may affect platelet function, increasing bleeding risk if an aneurysm ruptures, making it an inappropriate and potentially harmful recommendation for this client’s condition.
Choice B reason: Opioid analgesics are not routinely recommended for aneurysm management unless severe pain from rupture occurs. Prophylactic use is inappropriate, as it does not prevent aneurysm complications and may mask symptoms, delaying intervention. Lifestyle measures like avoiding strain are more relevant for prevention.
Choice C reason: Avoiding heavy lifting is critical for clients with an aneurysm, as increased intra-abdominal or thoracic pressure from lifting can elevate blood pressure, risking aneurysm rupture. This lifestyle modification reduces mechanical stress on the aneurysm wall, promoting safety and preventing catastrophic bleeding events.
Choice D reason: Including peanut butter, bread, or tart foods in the diet is unrelated to aneurysm management. Dietary choices do not directly affect aneurysm stability or rupture risk. Blood pressure control and avoiding strain, like heavy lifting, are more critical to prevent aneurysm complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
Choice A reason: A hemoglobin level of 15 g/dL is within the normal range and not consistent with aplastic anemia, which causes pancytopenia, including low hemoglobin due to bone marrow failure. Normal hemoglobin suggests adequate red blood cell production, ruling out aplastic anemia as the primary diagnosis.
Choice B reason: A platelet level of 275,000/mm3 is normal and does not support aplastic anemia, which involves bone marrow failure, leading to thrombocytopenia (low platelets). Normal platelet counts indicate intact megakaryocyte function, inconsistent with the pancytopenia characteristic of aplastic anemia’s bone marrow suppression.
Choice C reason: A white blood cell count of 1100 cells/mm3 indicates leukopenia, a hallmark of aplastic anemia. Bone marrow failure reduces production of all blood cell lines, including leukocytes, leading to low white cell counts, increasing infection risk, and supporting the diagnosis of aplastic anemia in this context.
Choice D reason: An erythrocyte count of 5.1 cells/mL is normal and not indicative of aplastic anemia, which causes anemia through reduced red blood cell production. Normal erythrocyte counts suggest preserved erythropoiesis, which is inconsistent with the pancytopenia expected in aplastic anemia’s bone marrow failure.
Correct Answer is B
Explanation
Reasoning:
Choice A reason: Aspiration precautions are important in head injury to prevent pneumonia, particularly if consciousness is impaired, but they are not specific seizure prophylactic measures. Seizures require anticonvulsants to prevent neuronal hyperexcitability, making aspiration precautions a secondary concern unrelated to seizure prevention.
Choice B reason: Anticonvulsant medications, initiated early (e.g., day two), are standard for seizure prophylaxis in head injury. Trauma can cause cortical irritation, increasing seizure risk. Drugs like levetiracetam stabilize neuronal activity, preventing seizures, which could worsen brain injury or ICP, making this the primary measure.
Choice C reason: Intubation and ventilator support are used for severe head injuries with compromised airway or breathing but are not seizure prophylaxis. Seizures are managed with anticonvulsants, as mechanical ventilation does not address neuronal excitability, making this inappropriate for seizure prevention.
Choice D reason: Antiemetic medications manage nausea but are not seizure prophylactic measures. While vomiting may occur post-head injury, it does not prevent seizures, which result from cortical irritability. Anticonvulsants directly target seizure risk, making antiemetics irrelevant to this specific intervention goal.
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