The nurse is caring for a client with a subarachnoid hemorrhage (SAH) complicated by a cerebral aneurysm. Which component of care is key to SAH management?

Blood pressure control.

Temperature maintenance.

Prophylactic antiepileptic initiation.

Glucose stabilization.

Answer and Explanation

The Correct Answer is A

A. Blood pressure control is the most critical component in the management of a client with a subarachnoid hemorrhage, particularly when a cerebral aneurysm is present. Elevated blood pressure increases the risk of aneurysm rupture or rebleeding, which can lead to catastrophic neurological deterioration. Maintaining blood pressure within a safe range helps reduce intracranial pressure and prevents further bleeding, directly impacting patient outcomes.

B. Temperature maintenance is important for overall neurological recovery, as hyperthermia can increase cerebral metabolism and worsen neurological injury. However, it is secondary to the immediate need for blood pressure control in preventing aneurysm rupture or rebleeding.

C. Prophylactic antiepileptic medications may be considered for some patients, especially those with seizures or high risk of seizures, but routine prophylactic initiation is not the primary focus of SAH management and does not address the most urgent risk of rebleeding.

D. Glucose stabilization is important for critically ill patients to prevent secondary brain injury from hyperglycemia, but it is supportive care and not the key intervention in SAH management.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Asking the client to describe the pain allows the nurse to obtain subjective information about the characteristics of the migraine. Quality refers to the type and nature of the pain, which provides insights into the pathophysiology and helps differentiate migraines from other types of headaches, such as tension-type headaches or cluster headaches. Clients may also describe associated symptoms like nausea, photophobia, or visual aura, which further informs clinical decision-making.

B. A numeric pain scale (e.g., 0–10) measures pain intensity, not quality. While it is useful to track the severity of pain over time, it does not provide information about whether the migraine is pulsating, throbbing, or sharp—information that is critical for identifying triggers and tailoring treatment.

C. Observing body language and movement can provide supportive information, particularly if the client is nonverbal or unable to communicate effectively. Signs such as guarding, facial grimacing, or changes in posture can suggest discomfort, but these observations cannot accurately define the type or quality of pain experienced during a migraine.

D. Identifying effective pain relief measures is important for planning ongoing management and evaluating previous treatment efficacy, but it does not assess the current characteristics or quality of the headache. This step is secondary to gathering subjective information about the pain itself.

A. "Hospice relies strictly on nonpharmaceutical measures to treat pain." B. "The main goal of hospice is to ensure the client dies with dignity." C. "Hospice assists the client and family in finding a cure." D. "Hospice follows a naturopathic model of healing."

Correct Answer is B

Explanation

A. Hospice care does not rely strictly on nonpharmaceutical measures. In fact, hospice emphasizes comprehensive pain and symptom management, including the use of medications such as opioids, antiemetics, and other pharmacologic therapies to ensure comfort and quality of life for the client. Limiting treatment to nonpharmaceutical measures would not align with standard hospice practices.

B. The primary goal of hospice is to ensure the client experiences a dignified, comfortable end-of-life experience while focusing on quality of life rather than curative treatment. Hospice provides physical, emotional, and spiritual support to both the client and family, addressing symptoms and promoting dignity in the final stages of life.

C. Hospice does not focus on curing the disease. Instead, it provides palliative care for clients with terminal illnesses when curative treatment is no longer the primary goal. Attempting to find a cure is contrary to the philosophy and eligibility criteria of hospice care.

D. Hospice care does not follow a naturopathic or alternative healing model exclusively. While some complementary therapies may be included to enhance comfort, hospice care is evidence-based and integrates both pharmacologic and nonpharmacologic approaches to symptom management rather than adhering to a strictly naturopathic approach.

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The nurse is caring for a client with a subarachnoid hemorrhage (SAH) complicated by a cerebral aneurysm. Which component of care is key to SAH management?

Nursing Test Bank

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