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 ["A","C","D"]
Explanation
A) Age 55 years:
Advancing age is a risk factor for skin cancer. As individuals age, the cumulative exposure to UV radiation increases, and the skin's ability to repair damage decreases, leading to a higher risk of skin cancer.
B) Yellow palms of the hands:
Yellow palms are typically associated with conditions like carotenemia or jaundice, not skin cancer. This symptom does not indicate an increased risk of developing skin cancer.
C) Light-colored hair:
Individuals with light-colored hair, especially those with fair skin and light eyes, are at higher risk for skin cancer. They often have less melanin, which provides some protection against UV radiation, increasing their susceptibility to damage from the sun.
D) Actinic keratosis on face:
Actinic keratosis is a precancerous skin lesion caused by long-term sun exposure. It is considered a significant risk factor for developing squamous cell carcinoma, a type of skin cancer. Presence of actinic keratosis should prompt careful monitoring and possibly treatment.
E) Poor skin turgor:
Poor skin turgor typically indicates dehydration or aging but is not directly related to an increased risk of skin cancer. It is more of a general indicator of skin and overall health rather than a specific risk factor for cancer.
Correct Answer is C
Explanation
(a) Diarrhea: Diarrhea is an abnormal gastrointestinal response characterized by frequent, loose, or watery stools. It can be caused by infections, medications, or underlying gastrointestinal disorders. Pallor, or paleness of the skin, typically does not directly lead to diarrhea unless there are specific underlying conditions affecting both circulation and gastrointestinal function.
(b) Diaphoresis: Diaphoresis refers to excessive sweating, which can occur due to sympathetic nervous system activation, fever, or anxiety. While diaphoresis may be associated with conditions causing increased sympathetic activity, it is not directly related to pallor, which indicates reduced blood flow to the skin.
(c) Fainting: Pallor is often a sign of decreased blood flow to the skin, indicating potential hypoperfusion. If severe, this reduced circulation can lead to fainting (syncope) due to inadequate blood supply to the brain. Therefore, after noting pallor, the nurse should be prepared to manage the client for potential fainting episodes by ensuring safety and providing appropriate interventions.
(d) Vomiting: Vomiting is the forceful expulsion of stomach contents through the mouth and can be caused by various factors such as gastrointestinal irritation, infection, or systemic illnesses. Pallor does not directly cause vomiting, although severe systemic conditions affecting circulation could potentially lead to nausea and vomiting as part of a broader clinical picture.
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