NCLEX-PN

Category - Basic Care

The nurse is tasked to care for a client who is admitted due to cerebral aneurysm. Which of the following actions of the nurse is the least effective in preventing rupture?
  1. Elevation of head 30 to 40 degrees, as ordered
  2. Administration of oxygen, as ordered
  3. Encouraging the client not to eat foods containing caffeine
  4. Limiting fiber intake
Explanation
Answer: D - In clients with cerebral aneurysm, the nurse should avoid activities that could increase the client’s intracranial pressure, as it can cause rupture. Limiting the fiber intake can cause constipation and straining, which increases the ICP. The other options are appropriate.
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