Author Question: A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which ... (Read 120 times)

viki · **on:** Jun 25, 2018

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?

a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of bed and assess for dizziness.
c. Encourage patient to cough and deep breathe every 4 hours.
d. Insert an oropharyngeal airway to prevent airway obstruction.

Question 2

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him.

Which nursing diagnosis is most appropriate for the patient?
a. Interrupted family processes related to effects of illness of a family member
b. Situational low self-esteem related to increasing dependence on spouse for care
c. Disabled family coping related to inadequate understanding by patient's spouse
d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

kingdude89 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

Answer to Question 2

ANS: C
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.