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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A) Correct- This is correct advice. Juice is not recommended for infants due to its high sugar content and lack of essential nutrients. It can contribute to excessive calorie intake and dental caries.
B) Incorrect- This is not accurate for a 9-month-old infant. By 9 months, most infants have already started to transition to solid foods, and their primary source of nutrition should be from a variety of solid foods, not formula.
C) Correct- This is correct advice. By 9 months, infants can begin to consume a variety of complementary foods to meet their nutritional needs. Adding raw fruit, cheese, or cooked vegetables can provide important nutrients and help introduce different tastes and textures.
D) Correct- As infants transition to solid foods, they typically require more frequent meals and snacks to meet their energy and nutrient needs. Breast milk or formula intake may also gradually decrease as solid foods are introduced.
E) Incorrect- Fluoride supplementation may be considered based on the fluoride content of the water supply and the child's risk of dental caries. However, this advice is not specific to the child's nutrition and feeding progression.
F. Incorrect- At 9 months, infants should not transition to whole cow's milk as their main source of nutrition. Breast milk or infant formula remains the primary source of nutrition, and cow's milk can be introduced as a beverage and ingredient in cooking after the first year of life.
Correct Answer is C
Explanation
Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.
Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.
While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.
Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.
Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.
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