A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?
Inquire about family history of headaches.
Review the client's medical record.
Assess the client's blood pressure.
Provide medication for pain relief.
The Correct Answer is C
(a) Inquire about family history of headaches:
While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.
(b) Review the client's medical record:
Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.
(c) Assess the client's blood pressure:
Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.
(d) Provide medication for pain relief:
Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens: Adolescents are particularly susceptible to TBIs due to their frequent involvement in contact sports like football, soccer, and hockey, as well as risky behaviors associated with driving. These activities are leading causes of TBIs in this age group, making education on safety measures and proper use of protective equipment essential in prevention efforts.
B) Females have twice the risk that males do: This statement is incorrect. In reality, males are more likely to sustain TBIs than females, especially in adolescence. The higher risk in males is largely due to their greater participation in high-impact sports and higher likelihood of being involved in motor vehicle accidents.
C) Falls occur more frequently in the younger population: Although falls are a significant cause of TBIs in young children and older adults, they are not the primary cause in adolescents. Teens are more likely to sustain TBIs from sports injuries and car accidents, making these areas more relevant for preventive education.
D) Most firearm incidents are accidental: While firearm-related TBIs can occur, they are not as common in the adolescent population compared to injuries from sports and motor vehicle accidents. Prevention efforts should focus more on the activities that pose the highest risk for this age group.
Correct Answer is ["A","B","C","D","E"]
Explanation
A) Location: Documenting the exact location of lesions is crucial for monitoring changes over time, assessing potential spread or resolution, and providing accurate information for future reference. This information helps in the diagnosis and in tracking the effectiveness of treatments.
B) Color: The color of lesions can provide important clues about their nature and cause. For example, red or inflamed lesions might indicate infection or irritation, while darker lesions could suggest malignancy or chronicity. Color changes can also signify healing or worsening of the lesion.
C) Condition of surrounding skin: Noting the condition of the skin around the lesions helps assess whether there is additional inflammation, infection, or other skin conditions that may be related to the primary lesion. This provides a more comprehensive understanding of the patient’s skin health and any secondary complications.
D) Elevation: Elevation refers to whether the lesion is raised, flat, or depressed compared to the surrounding skin. This characteristic helps in identifying the type of lesion, such as a papule, plaque, or ulcer. Elevated lesions might suggest certain dermatological conditions, while depressed lesions might indicate scarring or loss of tissue.
E) Distribution pattern: The pattern of how lesions are distributed on the body can provide diagnostic clues. For example, a linear distribution might suggest contact dermatitis, while a symmetrical distribution could indicate a systemic condition. Understanding the distribution pattern helps in identifying the underlying cause and planning appropriate treatment.
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