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) Facial edema: Myxedema is a severe form of hypothyroidism that is often characterized by the accumulation of mucopolysaccharides in the skin and other tissues, leading to facial and peripheral edema. This is a classic symptom of myxedema and is expected in clients with this condition.
B) Diarrhea: Diarrhea is more commonly associated with hyperthyroidism rather than hypothyroidism. Clients with myxedema typically experience constipation due to slowed gastrointestinal motility.
C) Tachycardia: Tachycardia is associated with hyperthyroidism. In contrast, myxedema is associated with bradycardia or a slow heart rate because of the overall slowing of the body's metabolic processes.
D) Heat intolerance: Heat intolerance is a symptom of hyperthyroidism. Clients with myxedema usually experience cold intolerance due to decreased metabolic activity and impaired thermoregulation.
Correct Answer is C
Explanation
A) Snellen chart:
The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.
B) Penlight:
A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.
C) Magazine:
A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.
D) Ophthalmoscope:
An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.
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