A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
Sit with the client for a few minutes.
Administer an analgesic.
Inform the nurse manager.
Call the health care provider immediately.
The Correct Answer is D
A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.
B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.
C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.
D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increasing forgetfulness and confusion: These symptoms are more characteristic of Alzheimer's disease or other types of dementia, not Parkinson's disease. While cognitive decline can occur in later stages of PD, it is not typically an initial symptom.
B. Tremors and muscle rigidity: Tremors (often starting in one hand) and muscle rigidity are hallmark initial symptoms of Parkinson's disease. These motor symptoms are among the most common early manifestations.
C. Visual disturbances and muscle weakness: Visual disturbances are not typically associated with early Parkinson's disease, and muscle weakness is not an initial symptom but could occur later due to rigidity and bradykinesia.
D. Fatigue and respiratory difficulties: While fatigue can occur, respiratory difficulties are not typically initial symptoms of Parkinson's disease and are more associated with later stages or other conditions.
Correct Answer is ["A","C","D"]
Explanation
A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.
B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.
C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.
D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.
E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.
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