A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?
Keep lights turned to medium level in the evening.
Maintain the head of the bed between 30 and 45°.
Administer hypotonic intravenous solutions.
Reposition the client every shift.
The Correct Answer is B
Choice A Reason:
Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.
Choice B Reason:
Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.
Choice C Reason:
Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.
Choice D Reason:
Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
African American clients is appropriate. Research suggests that African Americans have a lower prevalence of MS compared to White Americans, but they tend to have more severe disease progression and higher disability rates when diagnosed with MS.
Choice B Reason:
White American clients: Individuals of European descent, including White Americans, have the highest prevalence of MS, particularly those of northern European ancestry. MS is more common in populations of northern European descent compared to other racial and ethnic groups.
Choice C Reason:
East Asian clients: East Asians, including individuals of Chinese, Japanese, and Korean descent, have historically had lower rates of MS compared to individuals of European descent. However, MS prevalence appears to be increasing in East Asian populations, possibly due to changes in lifestyle and environmental factors.
Choice D Reason:
Hispanic or Latino clients: Studies suggest that the prevalence of MS is lower in Hispanic/Latino populations compared to White Americans but higher than in African Americans. However, there is considerable variation in MS prevalence among different Hispanic/Latino subgroups.
Choice E Reason:
Navajo Indian clients: Native American populations, including Navajo Indians, have been reported to have a lower prevalence of MS compared to individuals of European descent. However, limited data are available on MS prevalence and incidence in specific Native American tribes, and more research is needed to fully understand the disease burden in these populations.
Correct Answer is B
Explanation
Choice A Reason:
Drooling is inappropriate. Drooling, also known as sialorrhea, is a common symptom in Parkinson's disease due to impaired swallowing and reduced control of the muscles involved in saliva production. Anticholinergic medications can exacerbate dry mouth, which may contribute to drooling. However, drooling is not typically a side effect that would be specifically associated with anticholinergic use.
Choice B Reason:
Anhidrosis is appropriate. Anhidrosis refers to the inability to sweat normally. Anticholinergic medications can inhibit sweating by blocking the action of acetylcholine on sweat glands, leading to decreased sweating and potentially causing hyperthermia. Anhidrosis is a potential side effect of anticholinergic agents and should be reported to the healthcare provider due to the risk of overheating.
Choice C Reason:
Tremors is inappropriate. Tremors are a common symptom of Parkinson's disease and are typically not caused by anticholinergic medications. In fact, anticholinergic agents are often prescribed to help reduce tremors in individuals with Parkinson's disease. Tremors would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.
Choice D Reason:
Rigidity is inappropriate. Rigidity, or stiffness of the muscles, is a characteristic symptom of Parkinson's disease resulting from the loss of dopamine-producing neurons in the brain. While anticholinergic medications can help alleviate some symptoms of Parkinson's disease, they are not typically associated with rigidity. Rigidity would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.
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