The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

Ask if the client took any medication to treat the headache.

Refer the client to see an eye specialist.

Obtain the client's blood pressure.

Obtain a full history and physical.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Asking about medication use for headaches provides insights into pain management strategies but does not directly address underlying causes of symptoms. Vision changes and headaches may indicate neurological or cardiovascular issues, which require immediate investigation of vital signs like blood pressure to rule out hypertension or increased intracranial pressure.

Choice B rationale

Referring the client to an eye specialist addresses vision changes but neglects the acute nature of headaches. Hypertension or elevated intracranial pressure can affect both vision and cause headaches, and immediate assessment of these factors through blood pressure is more urgent.

Choice C rationale

Obtaining blood pressure evaluates for hypertension, which can manifest with headaches and visual disturbances due to increased arterial pressure affecting cerebral and ocular vessels. Normal blood pressure ranges are typically 120/80 mmHg. Immediate blood pressure measurement prioritizes acute care and mitigates potentially life-threatening conditions.

Choice D rationale

Obtaining a full history and physical is valuable for comprehensive care but delays immediate assessment of critical symptoms such as visual changes and headaches. Measuring blood pressure provides faster evaluation of acute conditions like hypertensive crisis or stroke risk.

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Correct Answer is D

Explanation

Choice A rationale

Assessing for hypotension is not indicative of fluid overload. Hypotension is more likely associated with hypovolemia or hemorrhage, whereas fluid overload manifests as signs of hypervolemia, including elevated blood pressure and pulmonary edema.

Choice B rationale

Assessing for distention above the pubis area identifies bladder retention or obstruction but is not directly related to monitoring fluid overload. Fluid overload affects systemic circulation and organ function rather than localized distention.

Choice C rationale

Monitoring laboratory values for hypernatremia is not an effective strategy for detecting fluid overload. Hypernatremia occurs due to inadequate water intake rather than excessive fluid administration. Fluid overload is typically identified by signs such as pulmonary congestion and generalized edema.

Choice D rationale

Maintaining strict intake and output records is crucial in detecting fluid overload. It helps identify disproportionate fluid retention compared to urinary output, signaling hypervolemia. Continuous monitoring ensures timely adjustments in fluid administration and prevents complications. .

A. Monitor the client for signs of hemorrhage. B. Monitor the incision site for signs of infection. C. Monitor the client's urine for sand or gravel. D. Monitor the percutaneous nephrostomy tube for signs of obstruction.

Correct Answer is C

Explanation

Choice A rationale

Hemorrhage is not a typical complication of extracorporeal shock wave lithotripsy (ESWL), as it is a non-invasive procedure targeting kidney stones using shock waves. The risk of significant bleeding is minimal, and monitoring focuses more on urinary changes or localized pain rather than hemorrhage.

Choice B rationale

ESWL does not involve surgical incisions, so there is no incision site to monitor for infection. This action is irrelevant to the procedure's mechanism, which uses external shock waves to fragment stones rather than invasive surgical methods.

Choice C rationale

Sand or gravel in the urine is a common finding after ESWL as the procedure fragments kidney stones into smaller particles. These fragments are excreted through the urinary system. Monitoring urine for these particles helps evaluate the procedure's effectiveness and ensure stones are adequately eliminated.

Choice D rationale

Percutaneous nephrostomy tubes are used for urinary drainage but are not a standard component of ESWL. Monitoring for tube obstruction applies to invasive procedures, whereas ESWL focuses on non-invasive stone fragmentation. This action is unrelated to the client's current treatment modality. .

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The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing postoperative care for a male client who had a transurethral resection of the prostate (TURP) 4 hours ago and has continuous irrigation.Which of the following actions should the nurse take to monitor the client for fluid overload?

Correct Answer is D

Explanation

The nurse is caring for a client after receiving extracorporeal shock wave lithotripsy (ESWL). Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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