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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hypovolemia. Following a serious thermal burn, the nurse takes action to prevent hypovolemia, which can result from fluid loss due to the burn. Hypovolemia can lead to hypoperfusion of vital organs, including the kidneys, and can cause acute renal failure. Preventing hypovolemia is critical to preventing other complications such as tissue hypoxia, cardiac failure, and infection.
A. Tissue hypoxia and cardiac failure are consequences of hypovolemia due to decreased blood flow to organs.
D. Infection is not the immediate complication to prevent but is a potential complication following burn injury.
Correct Answer is D
Explanation
Schedule injection on a nondialysis day. Epoetin is a medication used to stimulate the production of red blood cells. It is important to administer the medication on the day that the client is not receiving dialysis to prevent the medication from being removed from the bloodstream during the dialysis process.
Administering epoetin immediately after dialysis, choice B may result in decreased effectiveness.
Administering with low-dose aspirin, choice A, is not a standard recommendation for the administration of epoetin.
Monitoring the complete blood count prior to the dose, choice C is not the most important consideration when administering epoetin.
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