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. Measure nerve function in the fingers:
Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.
B. Monitor oxygen status:
Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.
C. Determine capillary refill:
The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.
D. Assess finger range of motion:
Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.
Correct Answer is D
Explanation
A) Size:
When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.
B) Consistency:
The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.
C) Shape:
Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.
D) Color:
Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.