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:
Falls is correct. Among individuals aged 65 years and older, falls are the most common cause of spinal cord injuries. As people age, they may experience changes in balance, mobility, and bone density, which can increase their risk of falling. Falls can occur both at home and in other environments, such as during outdoor activities or in healthcare settings. Spinal cord injuries resulting from falls in older adults can have significant consequences, including decreased mobility, chronic pain, and loss of independence.
Choice B Reason:
Gunshot wounds is incorrect. Gunshot wounds can cause spinal cord injuries, but they are not the most common cause for individuals aged 65 years and older. Gunshot wounds tend to be more common in younger age groups or in specific contexts such as violence-related incidents, which are less frequent in older adults.
Choice C Reason:
Sporting accidents is incorrect. Sporting accidents can also lead to spinal cord injuries, especially in younger and more active individuals participating in high-impact sports. However, among individuals aged 65 years and older, participation in sporting activities that could result in spinal cord injuries is generally less common compared to younger age groups.
Choice D Reason:
Motor vehicle accidents is incorrect.
Motor vehicle accidents can cause spinal cord injuries, but they are not as common in the elderly population as they are in younger age groups. Older adults may have reduced driving frequency or may be more cautious on the road, which decreases their risk of motor vehicle accidents compared to younger individuals.
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason:
Epithelial cells is correct. Epithelial cells lining the airways play a role in initiating the inflammatory response in asthma by releasing cytokines and other inflammatory mediators. These cells can contribute to the circulatory surge of inflammatory cells and cytokines seen in status asthmaticus.
Choice B Reason:
OT lymphocytes is incorrect. There is no specific cell type known as "OT lymphocytes." It's possible this may refer to T lymphocytes (T cells), which are involved in the immune response in asthma but are not typically associated with a circulatory surge in status asthmaticus.
Choice C Reason:
Hyperreactivity is incorrect. Hyperreactivity refers to the exaggerated response of the airways to various stimuli, leading to bronchoconstriction and inflammation. While hyperreactivity is a characteristic feature of asthma, it does not directly contribute to a circulatory surge of inflammatory cells and cytokines.
Choice D Reason:
Mast cells is correct. Mast cells are key players in the pathophysiology of asthma. They release various inflammatory mediators, including histamine and leukotrienes, which contribute to airway inflammation, bronchoconstriction, and mucus production. Mast cells can participate in the circulatory surge of inflammatory cells and cytokines in status asthmaticus.
Choice E Reason:
Inflammation is correct. Inflammation is a hallmark feature of asthma and plays a central role in the pathogenesis of status asthmaticus. The inflammatory response involves the recruitment and activation of various inflammatory cells, release of cytokines, and other mediators that contribute to airway obstruction and systemic effects.
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