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 B

Explanation

A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.

B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.

C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.

D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.

Correct Answer is []

Explanation

The potential condition the client is most likely experiencing is a Hemorrhagic Stroke.

Prepare the client for a STAT CT brain: The client presents with sudden onset of severe headache described as the worst of their life, along with additional neurological symptoms such as left-sided weakness, aphasia, photophobia, and loss of peripheral vision. These symptoms are highly concerning for a possible hemorrhagic stroke, which requires urgent imaging such as a CT scan of the brain to confirm the diagnosis and guide immediate treatment.
Place the client on seizure precautions: The client has reported left-sided weakness and aphasia, indicating neurological deficits. Additionally, they have a history of atrialfibrillation and are on anticoagulant therapy with warfarin, resulting in an elevated INR of4.9. This INR level suggests a significantly increased risk of bleeding, including intracranial bleeding. Given these factors, the client is at risk of experiencing seizures, which is a potential complication of hemorrhagic stroke. Placing the client on seizure precautionsinvolves ensuring their safety and preventing injury in the event of a seizure.

Parameters to Monitor:

Temperature: Monitoring temperature is important to assess for the presence of fever, which could indicate an infectious process such as meningitis. However, in this case, theclient's fever is likely related to their urinary tract infection rather than directly related to the stroke. Nonetheless, monitoring temperature is still essential for overall assessment and management.
PT/INR: Monitoring the PT/INR is crucial due to the client's history of atrial fibrillation and anticoagulant therapy with warfarin. The elevated INR of 4.9 suggests that the client is at increased risk of bleeding, including intracranial bleeding. Close monitoring of PT/INR levels will help guide adjustments to anticoagulant therapy and assess the risk of further bleeding complications.

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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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Explanation

Correct Answer is []

Explanation

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