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: Occult positive emesis, which indicates the presence of blood in vomit, is a critical finding. It suggests potential gastrointestinal bleeding, which requires immediate medical intervention. This condition can lead to significant blood loss and further complications if not addressed promptly.

Choice B reason: Strong foul-smelling flatus can indicate malabsorption or changes in gut flora, which are common after biliopancreatic diversion. While it can be unpleasant and concerning, it is not as immediately dangerous as gastrointestinal bleeding.

Choice C reason: A report of poor night vision could be related to vitamin A deficiency, which can occur after malabsorptive procedures like BPD. However, it is not an immediate threat compared to the risk of gastrointestinal bleeding.

Choice D reason: Loose bowel movements are common after BPD due to changes in digestion and absorption. While they can contribute to dehydration, they are not as urgent as the presence of blood in vomit.

A. Upper midabdominal pain described as gnawing and burning. B. Marked loss of weight and appetite over the last 3 or 4 months. C. Severe abdominal cramps and diarrhea after eating spicy foods. D. Frequent use of chewable and liquid antacids for indigestion.

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.

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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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