A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Administering hydromorphone as needed

Distracting the patient with activity

Dimming the lights and reducing stimulation

Initiating a patient-controlled analgesia (PCA) of morphine sulfate .

Answer and Explanation

The Correct Answer is C

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.

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Correct Answer is B

Explanation

Choice B rationale
Patients who experience severe cluster headaches should be instructed to take medications as soon as they sense the onset of symptoms. Cluster headaches are characterized by severe, debilitating pain that reaches peak intensity within a short period of time, often within 15 minutes. Therefore, early intervention is crucial to manage the pain effectively.
Choice A rationale

Waiting twenty to thirty minutes after the onset of symptoms to take medications may not be effective for cluster headaches. The pain of a cluster headache often reaches peak intensity within 15 minutes, so delaying medication could result in unnecessary suffering.
Choice C rationale
Waiting until the patient’s pain becomes unbearable is not recommended for managing cluster headaches. The goal of treatment is to prevent or reduce pain, not to wait until it becomes unbearable.
Choice D rationale
Taking medications when the patient senses their symptoms are peaking is not the most effective strategy for managing cluster headaches. Given the rapid onset and severe pain associated with cluster headaches, medications should be taken as soon as the patient senses the onset of symptoms.

A. Support the right arm with a sling or pillow to prevent shoulder dislocation. B. Anticipate the client will exhibit some degree of expressive or receptive aphasia. C. Place the wheelchair on the client’s left side when transferring him into a wheelchair. D. Provide close supervision because of the client’s impulsiveness and poor judgment.

Correct Answer is D

Explanation

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

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A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who experiences severe cluster headaches. At what point in the course of a new headache should the patient be instructed to take medications?

Correct Answer is B

Explanation

The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Correct Answer is D

Explanation

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