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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Toes cool to touch.
Choice A rationale: When a cast is too tight, it can compromise blood circulation to the extremity. This results in decreased blood flow and reduced oxygenation, causing the toes to feel cool to the touch.
Choice B rationale: Inability to move toes is a significant concern that can also indicate nerve compression due to a tight cast. However, it may not be the first sign of a tight cast, as impaired blood circulation will likely be evident before nerve damage.
Choice C rationale: Pallor of the toes, or a pale appearance, can occur when there is restricted blood flow. However, the coolness of the toes is often noticeable before pallor develops.
Choice D rationale: Edema of the toes, or swelling, can occur due to a tight cast, but it is usually a later sign. Initially, the toes may feel cool to the touch, followed by other symptoms such as pallor, pain, and eventually, swelling.
Correct Answer is D
Explanation
An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.
The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.
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