The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?

The stimulation can increase intracranial pressure (ICP)

The interaction may cause the client to become violent

The client may become emotional and lose interest in the treatment

The interaction may cause migraine in the client

Answer and Explanation

The Correct Answer is A

Reasoning:

Choice A reason: Limiting visitor interaction reduces stimulation, which can increase intracranial pressure (ICP) in clients with cerebral aneurysms. Emotional or physical stress from interactions raises blood pressure, potentially increasing ICP and risking aneurysm rupture, making this a critical measure to maintain stability and prevent catastrophic bleeding.

Choice B reason: Interaction causing violence is not a typical concern in cerebral aneurysm management. Aneurysms may cause neurological symptoms, but violence is unrelated to visitor interactions. The primary risk is increased ICP from stimulation, not behavioral changes, making this an incorrect rationale for limiting visitors.

Choice C reason: Emotional distress from interactions may occur but is not the primary reason to limit visitors. The main concern in cerebral aneurysms is preventing ICP increases from stimulation, which could lead to rupture. Emotional impact on treatment adherence is secondary to this immediate physical risk.

Choice D reason: Migraines are not a direct consequence of visitor interactions in cerebral aneurysm cases. While headaches may occur, the primary concern is increased ICP from stimulation, which raises blood pressure and risks aneurysm rupture, not triggering migraines, which are unrelated to this context.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: Feverfew, an herbal supplement, is sometimes used for migraines but has no proven role in aneurysm management. It may affect platelet function, increasing bleeding risk if an aneurysm ruptures, making it an inappropriate and potentially harmful recommendation for this client’s condition.

Choice B reason: Opioid analgesics are not routinely recommended for aneurysm management unless severe pain from rupture occurs. Prophylactic use is inappropriate, as it does not prevent aneurysm complications and may mask symptoms, delaying intervention. Lifestyle measures like avoiding strain are more relevant for prevention.

Choice C reason: Avoiding heavy lifting is critical for clients with an aneurysm, as increased intra-abdominal or thoracic pressure from lifting can elevate blood pressure, risking aneurysm rupture. This lifestyle modification reduces mechanical stress on the aneurysm wall, promoting safety and preventing catastrophic bleeding events.

Choice D reason: Including peanut butter, bread, or tart foods in the diet is unrelated to aneurysm management. Dietary choices do not directly affect aneurysm stability or rupture risk. Blood pressure control and avoiding strain, like heavy lifting, are more critical to prevent aneurysm complications.

A. Excessive thirst B. Low urine output C. Weight gain D. Excessive activities

Correct Answer is A

Explanation

Reasoning:

Choice A reason: Excessive thirst, or polydipsia, is a hallmark of diabetes insipidus. ADH deficiency leads to excessive water loss through dilute urine, causing dehydration. This triggers the thirst mechanism to compensate for fluid loss, prompting increased water intake to maintain hydration, a key clinical feature of this condition.

Choice B reason: Low urine output, or oliguria, is not associated with diabetes insipidus. This condition causes polyuria due to impaired water reabsorption from ADH deficiency, leading to large volumes of dilute urine. Low urine output is more typical of conditions like acute kidney injury or SIADH.

Choice C reason: Weight gain is not a feature of diabetes insipidus. The condition leads to water loss and dehydration, often causing weight loss due to reduced fluid volume. Weight gain might occur in conditions like SIADH, where water retention dilutes sodium and increases body fluid content.

Choice D reason: Excessive activities are not a clinical manifestation of diabetes insipidus. This condition primarily affects fluid balance, causing polyuria and polydipsia. Increased activity levels are not linked to ADH deficiency, and patients may experience fatigue due to dehydration, not heightened physical activity.

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The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has just been diagnosed with an aneurysm. When planning discharge teaching for this client, what instructions should the nurse provide to the client?

Correct Answer is C

Explanation

Which is a clinical manifestation of diabetes insipidus?

Correct Answer is A

Explanation

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