A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
Complaint of headache off and on for past month.
Nausea.
No bowel movement since yesterday.
Frequent voiding.
The Correct Answer is A
complaint of headaches off and on for the past month. A cerebral aneurysm is a bulging or ballooning in a blood vessel in the brain that can cause severe headaches or rupture, leading to bleeding in the brain. Therefore, a complaint of a headache is of greatest concern and requires immediate attention.
Nausea (B) is a common symptom associated with many disorders, and it may or may not be related to a cerebral aneurysm. No bowel movement since yesterday
(C) and frequent voiding (D) are not specific to cerebral aneurysms and may be caused by various other factors.
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Related Questions
Correct Answer is C
Explanation
Allow the client to follow your lead. This technique would be most beneficial for the ambulation of a visually impaired client. The nurse should allow the client to follow their lead because they are more familiar with their surroundings and can navigate better.
Option A, speaking before touching the client, is appropriate but not as effective as allowing the client to follow the nurse's lead.
Option B, providing a see-eye guide dog, may not always be feasible.
Option D, providing a detailed description of the room and walkway, may be helpful but not as effective as allowing the client to follow the nurse's lead.
Correct Answer is ["B","C","D"]
Explanation
The Glasgow Coma Scale (GCS) is a tool used to assess a patient's level of consciousness following a traumatic brain injury. It is based on three categories: eye-opening, verbal response, and motor response. The tool scores a patient from 3 to 15, with 15 being the best possible score. A score of 8 or less indicates a severe brain injury. The tool does not assess thought process or cognitive ability.
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