The nurse is planning care for the client with an aneurysm. A priority of care for this client is:
1. Carefully trimming finger- and toenails.
2. Limiting visitors.
3. Protecting from infection.
4. Addressing anxiety.
Answer: 4
1. Trimming the nails carefully is not necessary, since the client is not on anticoagulants.
2. Visitors do not need to be limited, and in fact should be encouraged, to help decrease the client's anxiety.
3. The client with an aneurysm is not immunosuppressed, and needs only normal preventive interventions.
4. Since an aneurysm can rupture at any time, most clients have a great deal of anxiety. This can stimulate the sympathetic nervous system and increase the blood pressure. The nurse should plan interventions to decrease anxiety as a priority of care.
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