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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale
Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.
Correct Answer is C
Explanation
Choice C rationale
Patients with Ménière’s disease are often advised to limit or avoid foods high in sodium, such as canned soup. High sodium intake can increase fluid retention, which can exacerbate the symptoms of Ménière’s disease, such as vertigo, tinnitus, and hearing loss.
Choice A rationale
There is no specific recommendation for patients with Ménière’s disease to limit or avoid red meat. However, a balanced diet that includes lean proteins is generally recommended for overall health.
Choice B rationale
Frozen yogurt is not specifically contraindicated for patients with Ménière’s disease. However, patients should be mindful of the sugar content, as high sugar intake can potentially trigger symptoms.
Choice D rationale
Shellfish is not specifically contraindicated for patients with Ménière’s disease. However, patients should be mindful of the preparation method and any added sodium, which can exacerbate symptoms.
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