A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Place the client in a darkened room.

Obtain blood pressure reading.

Administer an oral analgesic.

Perform finger stick glucose.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.

Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.

Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.

Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.

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Correct Answer is A

Explanation

Choice A reason: Upper midabdominal pain described as gnawing and burning is a classic symptom of peptic ulcer disease (PUD). This type of pain is typically located in the epigastric region and is often relieved by eating or taking antacids, which aligns with the presentation of PUD.

Choice B reason: Marked loss of weight and appetite over the last 3 or 4 months can occur in various gastrointestinal conditions, but it is not specific enough to support a diagnosis of PUD. This symptom alone does not provide enough evidence for PUD.

Choice C reason: Severe abdominal cramps and diarrhea after eating spicy foods might indicate irritable bowel syndrome (IBS) or another gastrointestinal condition. These symptoms are not typically associated with PUD.

Choice D reason: Frequent use of chewable and liquid antacids for indigestion can indicate chronic gastrointestinal discomfort, but it does not specifically point to PUD. It suggests ongoing gastric issues but lacks specificity for diagnosing PUD.

A. Petechial haemorrhage under client's eyes. B. Right lower abdomen rebound tenderness. C. Severe headache with photosensitivity. D. Dark green coloured emesis.

Correct Answer is B

Explanation

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

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A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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