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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Call the health care provider if stools are tarry: This instruction is more relevant to medications such as aspirin or NSAIDs, which can increase the risk of gastrointestinal bleeding.
Clopidogrel, while also an antiplatelet medication, is less likely to cause gastrointestinal bleeding compared to aspirin.
B. Clopidogrel will reduce cerebral artery plaque formation: Clopidogrel is an antiplatelet
medication that inhibits platelet aggregation, thereby reducing the formation of blood clots and potentially slowing the progression of atherosclerosis by preventing further plaque formation.
C. Clopidogrel will dissolve clots in the cerebral arteries: While clopidogrel can help prevent the formation of new clots, it does not actively dissolve existing clots in the cerebral arteries. Its primary mechanism of action is to inhibit platelet aggregation and prevent clot formation.
D. Monitor and record the blood pressure daily: While monitoring blood pressure is important for managing cerebral atherosclerosis and reducing the risk of stroke, it is not directly related to the action of clopidogrel. Blood pressure management may involve lifestyle modifications and other medications but is not specific to clopidogrel administration.
Correct Answer is ["B","D"]
Explanation
A. Slurred speech is often an early sign of increased ICP due to focal brain injury affecting speech areas.
B. Bradycardia is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and widened pulse pressure
C. Hypotension is not typically associated with increased ICP; in fact, hypertension may occur as the body attempts to maintain cerebral perfusion.
D. Nonreactive dilated pupils are a late sign of increased ICP, indicating potential compression of the third cranial nerve due to brain herniation.
E. Confusion can be an early or late sign of increased ICP, but it is not specific enough to be considered a definitive late sign without other context.
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