A nurse is caring for a client who has a cerebral aneurysm. In the event of a ruptured cerebral aneurysm, which of the following manifestations would be present in the client?
(Select All that Apply.)
Light sensitivity
Loss of consciousness
A dilated pupil
Visual disturbances
Nausea and vomiting
Numbness on one side of the face
Correct Answer : B,C,D,E
Choice A Reason:
Light sensitivity is incorrect. Light sensitivity (photophobia) is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur as a secondary symptom due to other neurological disturbances or increased intracranial pressure.
Choice B Reason:
Loss of consciousness is correct. Loss of consciousness is a common manifestation of a ruptured cerebral aneurysm, particularly if the bleeding leads to significant brain injury or compression of vital brain structures.
Choice C Reason:
A dilated pupil is correct. A dilated pupil (mydriasis) may occur as a result of compression of the oculomotor nerve (cranial nerve III) by the expanding hematoma or increased intracranial pressure following a ruptured cerebral aneurysm.
Choice D Reason:
Visual disturbances is correct. Visual disturbances, such as blurred vision, double vision (diplopia), or loss of vision, may occur due to compression of the optic nerve or damage to visual pathways as a result of the hemorrhage.
Choice E Reason:
Nausea and vomiting is correct. Nausea and vomiting are common symptoms associated with a ruptured cerebral aneurysm, often due to irritation of the meninges and increased intracranial pressure resulting from the bleeding.
Choice F Reason:
Numbness on one side of the face is incorrect. Numbness on one side of the face is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur if the hemorrhage affects specific regions of the brain responsible for sensation or if there is associated compression of cranial nerves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
MS hug is appropriate. The "MS hug" is a colloquial term used to describe a sensation of tightness, pressure, or squeezing around the torso or chest area experienced by some individuals with multiple sclerosis (MS). It is caused by spasms or contractions of the intercostal muscles (muscles between the ribs) or the diaphragm due to lesions in the spinal cord disrupting nerve signals. This sensation can be uncomfortable or painful for the individual.
Choice B Reason:
Lhermitte's sign is inappropriate. Lhermitte's sign is a common symptom experienced by individuals with MS but it presents differently. It is characterized by an electric shock-like sensation that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is caused by damage to the spinal cord's myelin sheath, leading to abnormal nerve signal transmission.
Choice C Reason:
Paroxysmal spasms is inappropriate. Paroxysmal spasms are sudden, involuntary muscle contractions or jerking movements that can occur in various parts of the body. While spasms are common in MS, they are not specifically associated with the sensation of tightness around the torso as described in the scenario.
Choice D Reason:
Trigeminal neuralgia is inappropriate. Trigeminal neuralgia is a condition characterized by sudden, severe facial pain often described as stabbing or electric shock-like. It is caused by irritation or damage to the trigeminal nerve, which is responsible for facial sensation. While individuals with MS may experience trigeminal neuralgia, it typically does not present with a tightening feeling around the torso.
Correct Answer is D
Explanation
Choice A Reason:
Osteoporosis is inappropriate. Chronic respiratory acidosis can lead to osteoporosis over time due to several factors, including chronic hypoxemia, which can affect bone metabolism and lead to bone loss.
Choice B Reason:
Polyuria is inappropriate. Polyuria, or increased urination, is not typically associated with chronic respiratory acidosis. In fact, respiratory acidosis tends to cause retention of bicarbonate ions, which can lead to compensatory metabolic alkalosis and decreased urine output.
Choice C Reason:
Anxiety and depression is inappropriate. Chronic respiratory acidosis can lead to symptoms such as lethargy, confusion, and decreased mental acuity due to the effects of elevated CO2 levels on the central nervous system. While anxiety and depression are not direct consequences of chronic respiratory acidosis, individuals with COPD may experience anxiety and depression as a result of their chronic respiratory condition.
Choice D Reason:
Delirium is correct. Delirium, characterized by an acute change in mental status, confusion, and altered consciousness, can occur in severe cases of chronic respiratory acidosis, especially during acute exacerbations. Elevated CO2 levels can affect brain function and lead to symptoms of delirium.
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