The nurse is caring for a client who is admitted to the hospital following rupture of an intracranial aneurysm. Nimodipine (Nimotop) is prescribed
Which assessment is most significant based on an understanding of the therapeutic effect of this drug for this client?
1. Measure blood pressure every 4 hours.
2. Auscultate cardiac rate and rhythm.
3. Observe for dependent edema.
4. Conduct frequent neurological checks.
Correct Answer: 4
Rationale 1: Although an elevation in blood pressure might indicate increased intracranial pressure, it is a less specific measure of brain cell injury than are findings of a different assessment.
Rationale 2: Although bradycardia might occur with brain cell injury, it is a less specific indicator of progression of neurological damage and insufficient therapeutic response to nimodipine (Nimotop) than is a different assessment.
Rationale 3: Neither the presence nor absence of dependent edema would indicate that a therapeutic effect is occurring for this client.
Rationale 4: Nimodipine (Nimotop) is given to reduce brain cell injury following rupture of a brain aneurysm. Frequent monitoring of neurological deficits is necessary to assess the therapeutic response to this drug.
Global Rationale: Nimodipine (Nimotop) is given to reduce brain cell injury following rupture of a brain aneurysm. Frequent monitoring of neurological deficits is necessary to assess the therapeutic response to this drug. Although an elevation in blood pressure might indicate increased intracranial pressure, it is a less specific measure of brain cell injury than are findings of a different assessment. Although bradycardia might occur with brain cell injury, it is a less specific indicator of progression of neurological damage and insufficient therapeutic response to nimodipine (Nimotop) than is a different assessment. Neither the presence nor absence of dependent edema would indicate that a therapeutic effect is occurring for this client.
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