A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
Complaint of headache off and on for past month.
Nausea.
No bowel movement since yesterday.
Frequent voiding.
The Correct Answer is A
complaint of headaches off and on for the past month. A cerebral aneurysm is a bulging or ballooning in a blood vessel in the brain that can cause severe headaches or rupture, leading to bleeding in the brain. Therefore, a complaint of a headache is of greatest concern and requires immediate attention.
Nausea (B) is a common symptom associated with many disorders, and it may or may not be related to a cerebral aneurysm. No bowel movement since yesterday
(C) and frequent voiding (D) are not specific to cerebral aneurysms and may be caused by various other factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.
Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.
Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.
Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.
Correct Answer is D
Explanation
Conductive hearing loss occurs when there is a blockage or damage in the outer or middle ear, which prevents sound from reaching the inner ear. The accumulation of cerumen in the ear canal can cause conductive hearing loss. Sensorineural hearing loss occurs due to damage to the inner ear or auditory nerve, while mixed hearing loss is a combination of both conductive and sensorineural hearing loss. Central hearing loss occurs due to damage in the central nervous system and is not related to cerumen buildup in the ear canal.
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