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 B

Explanation

Choice A rationale
A patient reporting a burning sensation is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice B rationale
A patient grimacing when they move is an objective sign of pain. It is observable and does not rely on the patient’s verbal report.
Choice C rationale

A patient rating their pain as an 8 on a scale of 0 to 10 is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice D rationale
A patient stating the pain is located in their abdomen is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.

A. Cancer pain B. Neuropathic pain C. Chronic pain D. Acute pain

Correct Answer is B

Explanation

Choice A rationale
Cancer pain is usually associated with the growth of a tumor or the side effects of cancer treatment. Phantom limb pain is not related to cancer.
Choice B rationale
Phantom limb pain is considered a type of neuropathic pain. This is because it is associated with nerve damage or malfunctioning nerves in the area where the limb was amputated.
Choice C rationale
Chronic pain is a broad term that refers to any pain that lasts for more than 12 weeks. While phantom limb pain can become chronic, this term does not specifically describe the type of pain experienced in phantom limb syndrome.
Choice D rationale
Acute pain is a type of pain that comes on suddenly and has a specific cause, usually related to tissue damage. Phantom limb pain is not considered acute pain because it is not related to new tissue damage.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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