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.

Answer and Explanation

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.

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.

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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.

A. Loss of vision in one eye B. Clear vision of nearby objects, but difficulty seeing distant objects C. Clear vision of distant objects, but difficulty seeing nearby objects D. Blurry vision of both distant and nearby objects

Correct Answer is C

Explanation

A) Loss of vision in one eye:

Loss of vision in one eye is not related to hyperopia (farsightedness). This condition could be due to various other causes such as retinal detachment, optic neuropathy, or trauma, but it does not describe the refractive error associated with hyperopia.

B) Clear vision of nearby objects, but difficulty seeing distant objects:

This description pertains to myopia (nearsightedness), where individuals can see nearby objects clearly but struggle with seeing distant objects. Hyperopia is the opposite, involving difficulty with near vision rather than distance vision.

C) Clear vision of distant objects, but difficulty seeing nearby objects:

Hyperopia, or farsightedness, is characterized by clear vision of distant objects while nearby objects appear blurry. This occurs because the eye's light focuses behind the retina rather than directly on it, making close-up tasks like reading challenging.

D) Blurry vision of both distant and nearby objects:

Blurry vision of both distant and nearby objects is not specific to hyperopia and may indicate other eye conditions such as astigmatism or severe refractive errors that affect overall visual acuity, rather than the specific issue of near vision seen in hyperopia.

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A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess a client's near vision. The nurse would use which piece of equipment for the assessment?

Correct Answer is C

Explanation

Which of the following best describes Hyperopia?

Correct Answer is C

Explanation

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