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","B","C"]
Explanation
Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).
The client has gestational diabetes mellitus (GDM), which is a condition that affects some pregnant women and causes high blood sugar levels. This is bad during pregnancy because it can increase the risk of complications for both the mother and the baby, such as preeclampsia, macrosomia, birth trauma, neonatal hypoglycemia, and congenital anomalies. The client needs to follow a diet and exercise plan to control her blood sugar levels and prevent further complications. She may also need to take insulin injections or oral medications if diet and exercise are not enough. The client should monitor her blood sugar levels regularly and report any abnormal results to her health care provider. The client should also have regular prenatal visits and ultrasounds to check the growth and development of the baby.
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A rationale: Repeating information may reinforce understanding but does not address the core barrier in unilateral hearing loss, which is sound localization and clarity. Auditory input from one ear limits binaural processing, making it harder to distinguish speech from background noise. Repetition without visual cues or proper orientation may still result in misinterpretation. Effective communication requires compensating for the sensory deficit, not merely reiterating content. Thus, repetition alone is insufficient for optimal education delivery.
Choice B rationale: Writing on a whiteboard provides visual support but lacks the dynamic interaction necessary for patient education. While visual aids help reinforce concepts, they do not allow for immediate clarification or emotional engagement. Pain management education involves nuanced discussion of pharmacologic options, side effects, and patient preferences. Relying solely on written communication may hinder comprehension, especially if literacy or cognitive load is a concern. It should supplement, not replace, direct verbal and visual interaction.
Choice C rationale: Speaking loudly into the affected ear is counterproductive and may distort sound further. In unilateral hearing loss, the affected ear has reduced or absent auditory function, and increasing volume does not restore clarity. Loud speech can also be perceived as aggressive or uncomfortable. Effective communication requires engaging the functional ear and using visual cues to enhance comprehension. Loudness does not compensate for neural deficits in auditory processing and may worsen patient experience.
Choice D rationale: Facing the client allows for optimal use of visual cues such as lip reading, facial expressions, and gestures, which are critical in compensating for unilateral auditory deficits. This technique engages the functional ear while supporting multimodal communication. It respects the neurophysiological limitations of monaural hearing and enhances speech perception through visual-auditory integration. Direct face-to-face interaction also fosters trust and allows for immediate feedback, making it the most scientifically sound approach for patient education.
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