A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Limit the client's ambulation to once a day.

Place the client in protective isolation.

Minimize environmental stimuli.

Elevate the head of the client's bed 45 degrees.

Answer and Explanation

The Correct Answer is C

A. Limiting ambulation is not a standard aneurysm precaution. While excessive activity should be avoided, strict bed rest is not always required unless specifically prescribed.
B. Protective isolation is not necessary for a client with an intracranial aneurysm, as the condition is not related to infection or immune suppression.
C. Minimizing environmental stimuli is essential to reduce stress, prevent increases in blood pressure, and decrease the risk of aneurysm rupture. A quiet, calm environment helps prevent sudden changes in intracranial pressure.
D. Elevating the head of the bed to 45 degrees may increase intracranial pressure. A more appropriate position is keeping the head of the bed elevated at 30 degrees to promote venous drainage while preventing excessive pressure on the aneurysm.

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Correct Answer is C

Explanation

A. “You might benefit from some psychological counseling." While psychological counseling may be helpful for coping with the emotional impact of epilepsy, it does not directly address the patient's concern about the possibility of having a seizure at work.

B. “The Department of Vocational Rehabilitation can help with work retraining." While
vocational rehabilitation services may be beneficial for individuals with disabilities, it may not directly address the patient's concern about continuing to work as a teacher.

C. "Epilepsy usually can be well controlled with medications." This response addresses the patient's concern by providing reassurance that epilepsy can often be effectively managed with medications. By effectively controlling seizures, the patient may be able to continue working without the fear of having a seizure at work.

D. “You will want to contact the Epilepsy Foundation for assistance." While the Epilepsy Foundation provides valuable resources and support for individuals with epilepsy, this response does not directly address the patient's concern about continuing to work.

A. Transfer the patient to radiology. B. Enforce NPO status for 4 hours. C. Help the patient to a lateral position. D. Administer a sedative medication.

Correct Answer is C

Explanation

A. Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B. Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C. Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D. Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.

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A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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