A nurse is providing care for a patient who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?

Maintain the head of the bed between 30 and 45 degrees.

Administer hypotonic intravenous solutions.

Keep lights turned to medium level in the evening.

Reposition the patient every shift.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Maintaining the head of the bed between 30 and 45 degrees is a common intervention for a patient at risk of cerebral aneurysm rupture. This position can help reduce intracranial pressure and promote venous drainage from the brain.
Choice B rationale
Administering hypotonic intravenous solutions is not typically recommended for patients at risk of cerebral aneurysm rupture. Hypotonic solutions can lead to cerebral edema, which can increase intracranial pressure and potentially contribute to aneurysm rupture.
Choice C rationale
Keeping lights at a medium level in the evening is not a specific intervention for patients at risk of cerebral aneurysm rupture. While maintaining a comfortable and restful environment is important, there’s no evidence to suggest that the level of lighting has a direct impact on the risk of aneurysm rupture.
Choice D rationale
Repositioning the patient every shift is a standard nursing intervention to prevent pressure ulcers and promote comfort. However, it is not a specific intervention for patients at risk of cerebral aneurysm rupture.

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Correct Answer is D

Explanation

Choice A rationale
Regulation of the amount of carbon dioxide exhaled can affect cerebral blood flow, but it does not directly maintain cerebral perfusion pressure constant.
Choice B rationale
Catecholamines circulating throughout the body can affect blood pressure and heart rate, but they do not directly maintain cerebral perfusion pressure constant.

Choice C rationale
How much blood is pumped from the heart, also known as cardiac output, can affect cerebral perfusion pressure. However, it does not directly maintain cerebral perfusion pressure constant.
Choice D rationale
Regulation of constriction and dilation of blood vessels in the brain, also known as cerebral autoregulation, is a key mechanism that maintains cerebral perfusion pressure constant. When pressure autoregulation is impaired, cerebral blood flow becomes dependent on cerebral perfusion pressure.

A. Bruising over the mastoid process B. Pooling of blood and edema around the eyes C. Ability to recall how the injury occurred D. Chvostek’s sign

Correct Answer is A

Explanation

Choice A rationale
Bruising over the mastoid process, also known as Battle’s sign, is a classic clinical sign of a basilar skull fracture.
Choice B rationale
Pooling of blood and edema around the eyes, or ‘raccoon eyes’, is another sign of a basilar skull fracture.
Choice C rationale
The ability to recall how the injury occurred is not directly related to the presence of a basilar skull fracture. Memory loss or confusion could be symptoms of a traumatic brain injury, but they are not specific to a basilar skull fracture.
Choice D rationale
Chvostek’s sign is a clinical sign of hypocalcemia, not a basilar skull fracture

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A nurse is providing care for a patient who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will maintain cerebral perfusion pressure constant?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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