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 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.
Correct Answer is A
Explanation
A) Fish: Fish, especially fatty fish like salmon, mackerel, sardines, and trout, are rich sources of omega-3 fatty acids. Omega-3 fatty acids are essential for heart health, reducing inflammation, and supporting brain function. Including fish in the diet is highly recommended for obtaining these beneficial fats naturally.
B) Leafy green vegetables: While leafy green vegetables provide many essential nutrients, they are not significant sources of omega-3 fatty acids. They are more commonly known for their vitamins, minerals, and fiber content, which are important for overall health but do not provide the omega-3s that fish does.
C) Corn oil: Corn oil is high in omega-6 fatty acids rather than omega-3 fatty acids. While omega-6 fatty acids are also necessary for health, they should be balanced with omega-3s to maintain optimal health. Corn oil does not contribute significantly to omega-3 intake.
D) Dietary supplements: While omega-3 supplements can be a good alternative for those who do not consume enough fish, obtaining nutrients from whole foods is generally preferred for additional health benefits, such as protein and other nutrients found in fish. Supplements should be considered when dietary intake is insufficient.
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