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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.
B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.
C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.
D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.
E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.
Correct Answer is C
Explanation
A. Prothrombin level: Although checking coagulation levels like prothrombin time may be important, it is not the first-line diagnostic tool for determining the type of stroke (ischemic or hemorrhagic), which is critical for treatment decisions.
B. Chest x-ray: A chest x-ray is not directly related to diagnosing or determining the type of stroke. It may be used for other purposes, such as assessing for respiratory issues, but it is not the priority in stroke diagnosis.
C. Brain CT scan or MRI: A brain CT scan or MRI is the most crucial diagnostic test to perform before initiating treatment for a stroke. This imaging helps differentiate between ischemic and hemorrhagic stroke, guiding the appropriate treatment approach.
D. Lumbar puncture: A lumbar puncture may be used in certain neurological evaluations but is not the first-line test for diagnosing a stroke. It is invasive and not typically performed in the acute setting for stroke evaluation.
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