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 A
Explanation
Monitoring the rate of IV infusions. In clients with diabetes insipidus, fluid therapy is essential to restore hydration levels. It is important to monitor the rate of IV infusion to avoid rapid administration of fluids, which can lead to fluid overload and pulmonary edema. Therefore, monitoring the rate of IV infusions is the most important intervention for this client.
Choice B, weighing the client daily, is incorrect because it is not the most important intervention for this client. While daily weighing is important for monitoring fluid balance, monitoring the rate of IV infusion is more critical.
Choice C, measuring the urine output every 30 minutes, is incorrect because although it is important to monitor urine output in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.
Choice D, measuring the fluid intake, is incorrect because although it is important to monitor fluid intake in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.
Correct Answer is B
Explanation
Ringing in the ears. Salicylate toxicity or salicylism is a condition that occurs when a client is taking large amounts of salicylates, which can result in symptoms such as tinnitus or ringing in the ears, nausea, vomiting, and diarrhea. Clients should report these symptoms to their healthcare provider immediately to prevent further complications.
Choice A, diarrhea, is not a symptom of salicylate toxicity, but rather a potential side effect of the medication in normal doses.
Choice C, dry eyes, and choice D, dry hacking cough, are not symptoms of salicylate toxicity.
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