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 A rationale
Instilling mineral oil into the canal and immediately irrigating to remove the impacted wax is not typically recommended. This approach may not allow enough time for the mineral oil to soften the cerumen, making it more difficult to remove and potentially causing discomfort or injury.
Choice B rationale
Instilling a small amount of mineral oil into the canal, then having the patient return in 30 minutes for wax removal is a common and effective method for managing cerumen impaction. The mineral oil helps to soften the cerumen, making it easier to remove through irrigation.
Choice C rationale
Irrigating the ear with cold water is not typically recommended. Cold water can cause discomfort and potentially lead to vertigo.
Choice D rationale
Irrigating the ear with warm water and a high amount of otic pressure is not typically recommended. High pressure can potentially damage the ear canal or tympanic membrane.

A. Maintain a patent airway B. Place an intravenous catheter (IV) C. Administer diazepam, per order D. Insert a nasogastric tube (NG)

Correct Answer is A

Explanation

Choice A rationale
Maintaining a patent airway is the highest priority when providing care for a patient in status epilepticus. Status epilepticus is a medical emergency characterized by prolonged or recurrent seizures. It can lead to severe complications, including respiratory distress and hypoxia.
Therefore, ensuring a patent airway is crucial to prevent hypoxia and further brain damage. This involves positioning the patient to prevent aspiration, potentially suctioning the airway, and providing supplemental oxygen as needed.
Choice B rationale
While placing an intravenous catheter (IV) is an important intervention, it is not the highest priority. An IV allows for the administration of medications and fluids, which are necessary in the management of status epilepticus. However, it is secondary to maintaining a patent airway.
Choice C rationale
Administering diazepam or other antiepileptic drugs is a key intervention in managing status epilepticus. These medications help to stop the seizures. However, medication administration should only occur after a patent airway has been established.
Choice D rationale
Inserting a nasogastric tube (NG) may be necessary in some cases to protect the airway or for administering medications or nutrition. However, this is not the highest priority intervention. The first step in managing status epilepticus is always to ensure a patent airway.

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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 patient is being evaluated for hearing loss. The doctor is unable to examine the tympanic membrane due to a blockage caused by cerumen. What actions can the nurse take to allow for an examination?

Correct Answer is B

Explanation

The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Correct Answer is A

Explanation

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