Difficulty: Medium
Average Score: 65%
Simulated
A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured?
Correct answer
D
Rationale
Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.