A nurse is attending to a client with multiple sclerosis who reports a sensation of tightness around their torso. What condition should the nurse identify this symptom as indicating?

Trigeminal neuralgia

Lhermitte’s sign

MS hug

Paroxysmal spasms

Answer and Explanation

The Correct Answer is C

Choice A rationale
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. It does not cause a sensation of tightness around the torso.
Choice B rationale

Lhermitte’s sign is a symptom of multiple sclerosis and other neurological conditions where a person feels an electric shock-like sensation running down the spine and into the limbs. It does not cause a sensation of tightness around the torso.
Choice C rationale
The sensation of tightness around the torso in a patient with multiple sclerosis is often referred to as the “MS hug”. It is caused by a lesion or an area of active inflammation within the spinal cord.
Choice D rationale
Paroxysmal spasms are a type of muscle spasm experienced by some people with multiple sclerosis. These spasms are usually painful and involve the muscles of the legs, but they do not cause a sensation of tightness around the torso.

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Correct Answer is A

Explanation

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.

A. Rebleeding of the injury B. Decreased cerebrospinal fluid C. Use of nimodipine D. Poor functional ability

Correct Answer is A

Explanation

Choice A rationale
Rebleeding of the injury is a significant factor related to a high mortality rate for a client who has a subarachnoid hemorrhage (SAH). SAH is a devastating event with substantial mortality and high morbidity among survivors. The most common primary causes of death or neurological devastation leading to withdrawal of support are direct effects of the primary hemorrhage (55%) and aneurysm rebleeding (17%)2. Therefore, rebleeding of the injury is a critical concern in the management of SAH.
Choice B rationale
Decreased cerebrospinal fluid is not directly linked to a high mortality rate in SAH. While changes in cerebrospinal fluid dynamics can occur after SAH, it’s not typically a primary factor contributing to mortality.
Choice C rationale
The use of nimodipine is actually part of the treatment protocol for SAH. Nimodipine is a calcium channel blocker that is used to prevent cerebral vasospasm, a complication of SAH. It does not contribute to a higher mortality rate.
Choice D rationale
Poor functional ability could be a result of SAH due to neurological damage, but it is not a direct cause of high mortality. The severity of the initial hemorrhage and subsequent

complications like rebleeding or medical complications are more directly tied to mortality rates.

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A nurse is attending to a client with multiple sclerosis who reports a sensation of tightness around their torso. What condition should the nurse identify this symptom as indicating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is assisting with planning care for a client who has a subarachnoid hemorrhage (SAH). Which of the following relates to a high mortality rate for a client who has an SAH?

Correct Answer is A

Explanation

A newly licensed nurse is learning about coup and contrecoup injuries. Which statement by the newly licensed nurse demonstrates a clear understanding of the topic?

A nurse is admitting a patient with a subarachnoid hemorrhage and expects to administer which of the following medications to decrease intracranial pressure (ICP)?

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 teaching a newly licensed nurse about the risk factors for subarachnoid hemorrhage (SAH). What should the nurse include in the teaching?

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