A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?
Inquire about family history of headaches.
Review the client's medical record.
Assess the client's blood pressure.
Provide medication for pain relief.
The Correct Answer is C
(a) Inquire about family history of headaches:
While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.
(b) Review the client's medical record:
Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.
(c) Assess the client's blood pressure:
Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.
(d) Provide medication for pain relief:
Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Loss of vision in one eye:
Loss of vision in one eye is not related to hyperopia (farsightedness). This condition could be due to various other causes such as retinal detachment, optic neuropathy, or trauma, but it does not describe the refractive error associated with hyperopia.
B) Clear vision of nearby objects, but difficulty seeing distant objects:
This description pertains to myopia (nearsightedness), where individuals can see nearby objects clearly but struggle with seeing distant objects. Hyperopia is the opposite, involving difficulty with near vision rather than distance vision.
C) Clear vision of distant objects, but difficulty seeing nearby objects:
Hyperopia, or farsightedness, is characterized by clear vision of distant objects while nearby objects appear blurry. This occurs because the eye's light focuses behind the retina rather than directly on it, making close-up tasks like reading challenging.
D) Blurry vision of both distant and nearby objects:
Blurry vision of both distant and nearby objects is not specific to hyperopia and may indicate other eye conditions such as astigmatism or severe refractive errors that affect overall visual acuity, rather than the specific issue of near vision seen in hyperopia.
Correct Answer is A
Explanation
A) Obesity II:
A Body Mass Index (BMI) of 37 falls within the range of 35 to 39.9, which is classified as Obesity Class II according to the World Health Organization (WHO) BMI categories. This classification indicates a higher risk of obesity-related health conditions and complications.
B) Overweight:
The overweight category corresponds to a BMI range of 25 to 29.9. A BMI of 37 is significantly higher than this range, indicating a more severe level of excess weight and associated health risks.
C) Normal weight:
Normal weight is defined by a BMI range of 18.5 to 24.9. A BMI of 37 is well above this range, indicating that the patient has excess body weight far beyond what is considered normal.
D) Obesity:
While the term "obesity" generally refers to a BMI of 30 or higher, specific classes of obesity (Class I, II, and III) are defined for more precise categorization. A BMI of 37 specifically places the patient in the Obesity II category.
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