A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Choice A reason: Providing total assistance with all ADLs is not an intervention that should be included in the client's plan. ADLs are activities of daily living, such as bathing, dressing, eating, and toileting. Providing total assistance with all ADLs can reduce the client's independence and self-esteem, and increase their dependence and learned helplessness. The nurse should encourage and assist the client to perform as much as they can by themselves and provide partial or intermittent assistance only when needed.

Choice B reason: Ordering a low-residue diet is not an intervention that should be included in the client's plan. A low-residue diet is a type of diet that limits foods that are high in fiber or indigestible material, such as whole grains, nuts, seeds, fruits, and vegetables. A low-residue diet may be recommended for clients who have inflammatory bowel disease (IBD), diverticulitis, or bowel obstruction, as it can reduce bowel frequency and irritation. However, it is not indicated for clients who have MS, unless they have other comorbidities that require it. A balanced diet that includes adequate fiber, fluids, and nutrients is more beneficial for clients who have MS.

Choice C reason: Encouraging the client to void every hour is not an intervention that should be included in the client's plan. Voiding every hour can be inconvenient and impractical for the client, and may not address their bladder problems effectively. MS can cause bladder dysfunction, such as urinary urgency, frequency, incontinence, or retention, due to nerve damage that affects bladder control. The nurse should assess the type and severity of the bladder dysfunction, and provide appropriate interventions, such as medication, catheterization, pelvic floor exercises, or bladder training.

Choice D reason: Instructing the client on daily muscle stretching is an intervention that should be included in the client's plan. Muscle stretching is a type of exercise that involves extending or elongating a muscle or group of muscles to their full length. Muscle stretching can help prevent or relieve muscle spasticity, stiffness, pain, or contractures that may occur in clients who have MS. The nurse should teach the client how to perform muscle stretching safely and correctly, and encourage them to do it daily or as prescribed.

Choice A reason: Repeat dose in 1 hour for unrelieved headache. This instruction is incorrect because sumatriptan should not be taken more than twice in 24 hours. Taking too much sumatriptan can cause serious side effects, such as high blood pressure, stroke, or heart problems.

Choice B reason: Chew the tablet well before swallowing. This instruction is incorrect because sumatriptan tablets should be swallowed whole with water. Chewing the tablet may affect its absorption and effectiveness.

Choice C reason: If you experience chest pain, call your physician immediately. This instruction is correct because chest pain is a serious and potentially life-threatening side effect of sumatriptan. Chest pain may indicate a heart attack or coronary artery spasm, which require immediate medical attention.

Choice D reason: Take daily to prevent headaches. This instruction is incorrect because sumatriptan is not a preventive medication for migraines. It is only used to treat acute migraine attacks when they occur. Taking sumatriptan daily can cause rebound headaches, which are worse and more frequent than the original ones.