NCLEX-PN® ExaminationPhysiological AdaptationHard
A client is admitted with a suspected ruptured cerebral aneurysm. The nurse notes a sudden, severe headache, nuchal rigidity, and photophobia. The client's Glasgow Coma Scale (GCS) score is 13. Which of the following is the priority nursing intervention?
- AAssist with activities of daily living and encourage ambulation.
- BMaintain a quiet, dimly lit environment and restrict visitors.
- CPrepare the client for an immediate lumbar puncture.
- DAdminister prophylactic antibiotics as prescribed.
Show answer & explanationAnswer & explanation
Correct answer: B. Maintain a quiet, dimly lit environment and restrict visitors.
Symptoms like sudden severe headache, nuchal rigidity, and photophobia, especially with a suspected ruptured cerebral aneurysm (subarachnoid hemorrhage), indicate meningeal irritation and increased intracranial pressure (ICP). Maintaining a quiet, dimly lit environment and restricting visitors helps minimize stimuli that could increase ICP or trigger vasospasm, which are critical complications.
Why the other options are wrong
- A. Encouraging ambulation and extensive ADLs would increase metabolic demand and potentially increase ICP, which is contraindicated in this condition.
- C. A lumbar puncture is contraindicated in suspected ruptured cerebral aneurysm until a CT scan rules out mass effect, as it can cause brain herniation due to pressure changes.
- D. Antibiotics are not a priority unless there's an active infection or for surgical prophylaxis, which is not the immediate concern here.
Ruptured Cerebral Aneurysm Priority Care
Priority nursing care for a suspected ruptured cerebral aneurysm (subarachnoid hemorrhage) focuses on preventing rebleeding, managing intracranial pressure, and reducing cerebral vasospasm.
- Symptoms include 'worst headache of life,' nuchal rigidity, photophobia.
- A quiet, calm environment is crucial to minimize stimuli and prevent ICP spikes.
- Strict blood pressure control and seizure precautions are also vital.
Memory trick: Quiet brain, low light, prevents the aneurysm's bite!