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 ["35 "]
Explanation
Step 1 is to calculate the total daily dosage in milligrams. This is done by multiplying the weight of the client by the ordered daily dosage. So, 70 kg × 25 mg/kg = 1750 mg/day.
Step 2 is to divide the total daily dosage by the number of doses per day to get the dosage per dose. So, 1750 mg ÷ 2 = 875 mg/dose.
Step 3 is to calculate the volume of the dose in milliliters. The supply of Amoxicillin is 125 mg/5 mL, which means there are 125 mg of Amoxicillin in every 5 mL. So, to find out how many milliliters contain 875 mg, we set up a proportion: (125 mg / 5 mL) = (875 mg / x mL). Solving for x gives x = (875 mg × 5 mL) ÷ 125 mg = 35 mL. Therefore, the correct dosage for one dose is 35 mL.
Correct Answer is C
Explanation
Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.
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