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
Explanation
(a) Liver Disease:
Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.
(b) Diabetes mellitus:
While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.
(c) End Stage Renal Disease:
End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.
(d) Colon Cancer:
Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.
Correct Answer is C
Explanation
A. Acanthosis Nigricans:
Acanthosis nigricans is characterized by dark, velvety patches of skin, often found in body folds such as the neck, armpits, and groin. It does not present as the yellow discoloration seen in the photo.
B. Cyanosis:
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. The image shows yellow discoloration, not the blue tint associated with cyanosis.
C. Jaundice:
Jaundice is indicated by a yellowish tint to the skin and sclera due to elevated bilirubin levels, commonly associated with liver dysfunction. The photo clearly shows this yellow discoloration, consistent with jaundice, often seen in chronic alcoholics with liver disease.
D. Carotenemia:
Carotenemia presents as a yellow-orange discoloration of the skin, especially on the palms and soles, due to high levels of carotene in the blood. It does not typically affect the sclera, which differentiates it from jaundice. The uniform yellowing of the skin and eyes in the photo aligns more with jaundice.
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