A patient has been hospitalized for scheduled repair of an intracranial aneurysm
The nurse caring for the patient prior to surgery would recognize which manifestations as indicating the aneurysm may be leaking or may have ruptured? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Visual deficits
2. Headache
3. Mild nausea
4. Dilated pupil
5. Stiff neck
1,2,4
Rationale 1: The most common cranial nerve signs are dilated pupil, decreased mobility of the eye, and ptosis.
Rationale 2: The most common complaint is "the worst headache of my life.".
Rationale 3: Nausea is not a prodromal sign, but it may be present once rupture has occurred.
Rationale 4: Pupil dilation is a common prodromal finding.
Rationale 5: Stiff neck is not a prodromal sign of intracranial aneurysm.
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