A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

Obtain a throat culture specimen.

Perform a complete blood count.

Check the client's temperature.

Administer an oral analgesic.

Answer and Explanation

The Correct Answer is C

A. Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.

C. Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.

D. Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.

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Correct Answer is A

Explanation

The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.

Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.

A. Auscultation of lungs revealing wheezing B. A bounding distal pulse C. Fever D. Pain unrelieved by opioid analgesic

Correct Answer is D

Explanation

a. Auscultation of lungs revealing wheezing is not related to venous return in the aﬀected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.

b.A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.

c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.

d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.

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A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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