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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Her family will no longer be dysfunctional." Completing a treatment program does not guarantee that family dynamics will change or improve immediately. Family dysfunction is often deeply rooted and requires separate or concurrent therapy.
B. "She'll need ongoing support to remain abstinent." Recovery from alcoholism is an ongoing process, and continued support, whether through therapy, support groups, or counseling, is critical to maintaining abstinence and preventing relapse.
C. "She doesn't need to be concerned about abusing alcohol in the future." This statement is inaccurate because individuals recovering from alcoholism must remain vigilant to prevent relapse. Alcoholism is a chronic condition, and the risk of relapse remains.
D. "She can learn to consume alcohol without problems." This is incorrect, as individuals who have struggled with alcoholism typically need to abstain completely from alcohol to prevent relapse.
Correct Answer is D
Explanation
A. Place the client on his back, remove dangerous objects, and insert a bite block. Placing a client on their back during a seizure increases the risk of airway obstruction, and inserting a bite block is not recommended as it can cause injury.
B. Place the client on his side, remove dangerous objects, and insert a bite block. While positioning the client on their side is correct, inserting a bite block is contraindicated due to the risk of injury to the client.
C. Place the client on his back, remove dangerous objects, and hold down his arms. Restraining a client during a seizure is not recommended as it can cause injury. Placing the client on their back also poses a risk of airway obstruction.
D. Place the client on his side, remove dangerous objects, and protect his head. Positioning the client on their side helps maintain airway patency, removing dangerous objects prevents injury, and protecting the head helps prevent head trauma during the seizure.
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