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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reasoning:
Choice A reason: Iron deficiency anemia is a risk post-gastric bypass due to reduced stomach acid and bypassed duodenum, impairing iron absorption. Pantoprazole, a proton pump inhibitor, further reduces acid, exacerbating malabsorption. Fatigue results from low hemoglobin, as iron is essential for red blood cell production, matching the client’s profile.
Choice B reason: Aplastic anemia, caused by bone marrow failure, is not linked to gastric bypass or pantoprazole. It results from autoimmune, toxic, or idiopathic causes, leading to pancytopenia. The client’s surgical history and medication use point to malabsorption, not bone marrow suppression, ruling out this anemia.
Choice C reason: Sickle cell anemia is an inherited hemoglobinopathy, not related to gastric bypass or pantoprazole. It causes hemolytic anemia and vaso-occlusive crises, not malabsorption-related fatigue. The client’s surgical history suggests an acquired nutritional deficiency, making iron deficiency more likely than sickle cell disease.
Choice D reason: Pernicious anemia results from vitamin B12 deficiency, often due to lack of intrinsic factor, which may occur post-gastric bypass. However, pantoprazole primarily impairs iron absorption, and fatigue with this history points to iron deficiency, as B12 absorption is less affected in this scenario.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Acknowledging the client’s relief does not educate them about the TIA’s significance. TIAs indicate transient cerebral ischemia, increasing stroke risk, but this response fails to address the need for risk modification, missing an opportunity to promote preventive measures critical for stroke prevention.
Choice B reason: Stating that TIA symptoms resolve within 24 hours is factually correct but does not emphasize the serious nature of TIAs as stroke precursors. Without addressing risk reduction, this response fails to educate the client on the need for lifestyle changes or medical intervention to prevent future events.
Choice C reason: Saying all TIA patients will develop a stroke is inaccurate, as not all progress to stroke. TIAs significantly increase stroke risk, but many can be prevented with proper management. This response is overly fatalistic and does not encourage proactive risk reduction strategies.
Choice D reason: Explaining that a TIA is a warning sign and discussing risk reduction educates the client about its significance as a transient cerebral ischemia event, increasing stroke risk. This response promotes lifestyle changes, medication adherence, and medical follow-up, empowering the client to prevent future strokes effectively.
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