The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply.

1.Provide physical aspects of care.

2.Prevent pushing or straining activities.

3.Limit caffeinated coffee to 1 cup per day.

4.Keep the lights on in the client's room.

5.Maintain the head of the bed at 15 degrees.

1.Provide physical aspects of care.

2.Prevent pushing or straining activities.

5.Maintain the head of the bed at 15 degrees.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions would be included in the plan? Select all that apply.

1.Leave the lights on in the client's room at night.

2.Place a blood pressure cuff at the client's bedside.

3.Close the shades in the client's room during the day.

4.Allow the client to drink 1 cup of caffeinated coffee a day.

5.Allow the client to ambulate 4 times a day with assistance.

2.Place a blood pressure cuff at the client's bedside.

3.Close the shades in the client's room during the day.

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client?

1.Keep the window blinds open.

2.Turn on a small spotlight above the client's head.

3.Make sure the door to the room is open at all times.

4.Prohibit or limit the use of a radio or television and reading.

4.Prohibit or limit the use of a radio or television and reading.

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse would plan to avoid taking which action when giving respiratory care to this client?

1.Encouraging hourly coughing

2.Assisting with incentive spirometer

3.Encouraging hourly deep breathing

4.Repositioning gently side to side every 2 hours

1.Encouraging hourly coughing

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply.

1.Mild drowsiness

2.Drooping eyelids

3.Ptosis of the left eyelid

4.Slight slurring of speech

5.Less frequent spontaneous speech

1.Mild drowsiness

4.Slight slurring of speech

5.Less frequent spontaneous speech

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply.

1.Basilar artery

2.Vertebral artery

3.Anterior cerebral artery

4.Internal carotid arteries

5.Posterior cerebral artery

3.Anterior cerebral artery

4.Internal carotid arteries

5.Posterior cerebral artery