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

Check the patient's blood temperature.

Administer an oral analgesic.

Perform a complete blood count.

Evaluate the patient's neurological status.

Answer and Explanation

The Correct Answer is A

A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.

B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).

C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.

D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Tachycardia does not occur with autonomic dysreflexia.

B. Autonomic dysreflexia is a life-threatening condition caused by a noxious stimulus (e.g., full bladder, constipation) in patients with spinal cord injuries above T6. It leads to severe hypertension and reflex bradycardia.

C. Hypotension is not a symptom; autonomic dysreflexia causes hypertension.

D. Tachycardia and hypotension are more associated with spinal shock rather than autonomic dysreflexia.

A. Improve venous circulation and prevent VTE formation B. Prevent flexion and contractures of the extremities C. Decrease the development of a paralytic ileus D. Prevent the development of pressure ulcers

Correct Answer is D

Explanation

A. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.

B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.

C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.

D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observing a client with autonomic dysreflexia would expect which of the following clinical manifestations?

Correct Answer is B

Explanation

A 22-year old patient involved in a motorcycle accident has a complete transection of the spinal cord at T-8 resulting in paraplegia. Nursing interventions includes repositioning the patient every 1-2 hours to:

Correct Answer is D

Explanation

What information will the nurse provide to the visitors of a patient who is to receive a bone marrow transplant?

A nurse is assessing a patient who has diabetes mellitus. Which of the following findings is a manifestation of hypoglycemia?

A nurse is planning care for a patient who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

Which of the following evaluation data would the nurse recognize that a patient with hyperosmolar hyperglycemic syndrome (HHS) has improved during the first 24 hours upon admission to the hospital?

A patient has new onset type I diabetes mellitus and asks why they need to check their blood glucose level so often. The nurse explains frequent monitoring is necessary to keep the blood glucose level stable for which of the following reasons?

A patient with diabetic ketoacidosis (DKA) has been receiving insulin for 6 hours. Laboratory finding are Na+ 131, K+ 3.7, CL- 102, HCO3 22, and glucose 170. Which action should the nurse take?

A nurse is caring for a patient who has a T-4 spinal cord injury. Which of the following patient findings should the nurse identify as placing the at risk for developing autonomic dysreflexia?

When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?