A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder.
Complete the following sentence by using the list of options.
The nurse should first address the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The nurse and address the clients right shoulder pain after addressing the clients drowsiness. a clients recovery can be affected by pain by inhibiting their ability to become active and involved in self-care. The goal is to provide pain relief so that the client is able to participate in the recovery and to improve the clients functional status. Assessment of paint should include intensity, quality, duration, and location.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The patient had a recent acute myocardial infarction: Sumatriptan is contraindicated in patients with a history of myocardial infarction or coronary artery disease due to its vasoconstrictive effects, which could exacerbate ischemia or precipitate cardiovascular events.
B. The patient has had migraine headaches for 30 years: While the duration of migraine headaches is relevant to the patient's history, it is not as immediately concerning as a recent myocardial infarction when considering the use of sumatriptan.
C. The patient drinks 1 to 2 cups of coffee daily: While caffeine consumption may interact with sumatriptan and affect its efficacy or side effects, it is not as immediately concerning as a recent myocardial infarction.
D. The patient has taken topiramate (Topamax) for 2 months: While the use of topiramate may interact with sumatriptan, it is not as immediately concerning as a recent myocardial infarction. However, it is still important to report all medications the patient is taking to the healthcare provider.
Correct Answer is []
Explanation
The client is most likely experiencing meningitis based on the following clinical manifestations:
- Symptoms: The client presents with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, general muscle aches, diarrhea, abdominal pain, sore throat, sensitivity to light, and intermittent nystagmus. These symptoms are consistent with the classic signs of meningitis, including headache, nausea, vomiting, photophobia, and altered mental status.
- Physical Examination Findings: The physical examination reveals a fever (temperature of 38.9°C or 102°F), elevated heart rate (118/min), and signs of meningeal irritation such as neck stiffness (not directly mentioned but implied by headache and sensitivity to light). Additionally, a pinpoint, red, macular rash on the upper chest may indicate petechiae, which can be seen in meningococcal meningitis.
Given the suspicion of meningitis, the nurse should take the following actions:
- Implement seizure precautions: Meningitis can lead to increased intracranial pressure and neurological complications, including seizures. Implementing seizure precautions involves ensuring the client's safety by padding the side rails of the bed, keeping the bed in a low position, and providing close observation.
- Dim the lights in the client’s room: The client reports sensitivity to light, which is a common symptom of meningitis due to meningeal irritation. Dimming the lights can help reduce discomfort and photophobia in the client.
Parameters to Monitor:
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Neurologic status: Monitoring the client's neurologic status is crucial for assessing the progression of meningitis and detecting any neurological deterioration, such as changes in level of consciousness, motor deficits, or signs of increased intracranial pressure.
- Temperature: Monitoring the client's temperature is essential to assess for fever spikes or trends, which can indicate the severity of the infection and response to treatment.
Persistent or worsening fever may suggest inadequate treatment or complications such as abscess formation.
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