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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.
B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.
C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.
D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.
Correct Answer is B
Explanation
A. Monro-Kellie hypothesis: The Monro-Kellie hypothesis explains the relationship between the volumes of brain tissue, blood, and cerebrospinal fluid in the cranium, but it is not a diagnostic tool for assessing LOC.
B. Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a standardized tool used to assess a client's level of consciousness, particularly in cases of head injury. It evaluates eye opening, verbal response, and motor response.
C. Cranial nerve function: Cranial nerve assessment is important in evaluating neurological function, but it is not a comprehensive tool for gauging LOC.
D. Mental status examination: A mental status examination assesses cognitive functions, but the Glasgow Coma Scale is more appropriate for evaluating LOC in the context of head trauma.
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