A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Sit with the client for a few minutes.

Administer an analgesic.

Inform the nurse manager.

Call the health care provider immediately.

Answer and Explanation

The Correct Answer is D

A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.

B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.

C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.

D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.

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Correct Answer is B

Explanation

A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.

B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.

C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.

D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.

A. Assisting the client with meals B. Placing food on the affected side of the mouth C. Testing the gag reflex before offering food or fluids D. Allowing ample time to eat

Correct Answer is B

Explanation

A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.

B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.

C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.

D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.

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A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Correct Answer is B

Explanation

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