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.
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.
You might also like to view...
A client does not participate in group sessions due to feeling inferior to others in the group. Based on cognitive theory, he would be directed to:
a. Review his previous relationship with his parents. b. Participate in group to receive extra privileges. c. Suppress negative thoughts about the group. d. Recognize and change his negative thoughts.
The nurse working the telephone suicide crisis line receives a call from a man who tells her he lives alone in a home several miles from his nearest neighbors. He has been considering suicide for 2 months
He has had several drinks and has loaded his shotgun, with which he plans to shoot himself in the chest. How should the nurse assess the lethality of this plan? a. No risk b. A low level of lethality c. A moderate level of lethality d. A high level of lethality
A patient's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells?
A) Suppressor T cells B) Memory T cells C) Cytotoxic T cells D) Complement T cells
Persistent and progressive hoarseness is usually the earliest symptom of laryngeal cancer
Indicate whether the statement is true or false