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.

Answer and Explanation

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.

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.

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Correct Answer is C

Explanation

A) Blockage of the tear ducts causing excessive tearing:

Blockage of tear ducts (dacryostenosis) results in excessive tearing (epiphora) due to inadequate drainage of tears into the nasal cavity. It does not directly contribute to glaucoma, which primarily involves increased intraocular pressure (IOP) and optic nerve damage.

B) Inflammation of the cornea resulting in blurry vision:

Corneal inflammation (keratitis) can cause blurry vision, pain, and sensitivity to light, but it is not the primary pathophysiology of glaucoma. Glaucoma primarily involves damage to the optic nerve due to elevated IOP.

C) Increased intraocular pressure (IOP) leading to optic nerve damage:

Glaucoma is characterized by elevated IOP, which puts pressure on the optic nerve and can lead to progressive damage and vision loss if untreated. This is the primary pathophysiological process in most types of glaucoma.

D) Degeneration of the lens leading to cataracts:

Cataracts involve the clouding of the lens of the eye, leading to visual impairment. While cataracts are a common condition in older adults, they are not directly related to the pathophysiology of glaucoma, which primarily involves elevated IOP and optic nerve damage.

A. Encourage the client to look at the balance beam B. Have the client wear the same clothing every day. C. Weigh the client at the same time in the morning D. Use the same scale to weigh the client. E. Discuss the client's weight with her after each measurement.

Correct Answer is ["B","C","D"]

Explanation

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the primary pathophysiology of glaucoma?

Correct Answer is C

Explanation

A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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