The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take?
Elevate head of bed no higher than 30 degrees.
Affirm blood glucose is below 160 mg/dL (8.88 mmol/L)
Check for a stat intravenous diuretic prescription.
Obtain a manual blood pressure measurement.
The Correct Answer is D
A pounding headache in a client with COPD may be a symptom of increased carbon dioxide (CO2) levels in the blood, known as hypercapnia. Hypercapnia can lead to vasodilation, resulting in headaches. In this situation, it is crucial to assess the client's blood pressure to determine if it is elevated, as this could be contributing to the headache.
Obtaining a manual blood pressure measurement allows for a more accurate assessment of the client's blood pressure compared to automated measurements. It is important to assess both systolic and diastolic blood pressures, as elevated blood pressure can worsen headaches and have other negative effects on the client's health.
Elevating the head of the bed no higher than 30 degrees is a general measure used to improve respiratory function in clients with COPD. However, in this specific situation, it may not directly address the pounding headache. Elevating the head of the bed can help reduce dyspnea and improve oxygenation, but it may not alleviate the headache caused by hypercapnia.
Affirming blood glucose levels are below 160 mg/dL (8.88 mmol/L) is not the primary concern in this case. While high blood glucose levels can have various effects on the body, including headaches, the priority is to assess the client's blood pressure due to the specific context of a COPD exacerbation.
Checking for a stat intravenous diuretic prescription is not necessary in response to the client's headache. Diuretics are typically used to remove excess fluid from the body and may not directly address the underlying cause of the headache in this situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.
Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
Correct Answer is A
Explanation
The information that the nurse should obtain from the client first is: Reason for taking the aspirin.
It is important to first understand why the client was taking aspirin in order to determine the potential implications of switching to ibuprofen. Aspirin and ibuprofen are both nonsteroidal anti-inflammatory drugs (NSAIDs), but they have different indications and effects. Aspirin is commonly used for its antiplatelet properties to reduce the risk of heart attacks and strokes, while ibuprofen is primarily used for its analgesic and anti-inflammatory properties.
By understanding the reason for taking aspirin, the nurse can assess if the client was using it for its antiplatelet effects, which is important information to consider for the client's overall health and well-being.
Once the reason for taking aspirin is determined, the nurse can proceed to inquire about the other relevant information, such as the dosage of ibuprofen taken, presence of gastric pain, and amount of pain control. These details will help in assessing the client's current medication regimen, potential side effects or complications, and overall pain management.
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