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.
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.
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Related Questions
Correct Answer is D
Explanation
A. Chart – Contains patient information but is not used for immediate verification before transfusion.
B. Order sheet – Ensures the transfusion is ordered but does not confirm patient identity.
C. Medication administration record – Lists medications but is not used to verify transfusion identity.
D. Identification wristband – Correct Answer. The wristband is the most accurate and immediate source for patient verification before administering blood products.
Correct Answer is D
Explanation
A. Eat plenty of fresh fruits and vegetables. – Incorrect. Raw fruits and vegetables can harbor bacteria, increasing the risk of infection for a patient with neutropenia.
B. Take temperature weekly. – Incorrect. Patients with neutropenia should check their temperature daily, as fever may be the first sign of infection.
C. Perform mild exercise, such as gardening. – Incorrect. Gardening exposes the patient to soilborne fungi and bacteria, which can be harmful.
D. Avoid crowds. – Correct Answer. Neutropenic patients are highly susceptible to infections, so avoiding crowds helps reduce the risk of exposure to contagious illnesses.
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