A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Place the client in a darkened room.

Obtain blood pressure reading.

Administer an oral analgesic.

Perform finger stick glucose.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.

Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.

Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.

Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Telling the client to lay on the left side to prevent the tongue from falling back into the mouth is not a standard intervention for managing swallowing difficulties in Parkinson's disease. The focus should be on dietary modifications and safe swallowing techniques.

Choice B reason: Teaching the client to take medication an hour before meals to enhance the swallowing reflex is not a widely recognized intervention for managing swallowing difficulties. While timing of medication can be important, dietary adjustments are more immediately effective.

Choice C reason: Preparing the client and family for the future need of a gastrostomy tube for feeding might be necessary if swallowing difficulties progress significantly. However, it is not the first line of intervention and should be considered only after other measures have been tried.

Choice D reason: Encouraging the client and family to provide a semi-solid diet with thick liquids is the most appropriate intervention. Semi-solid and thickened liquids are easier to swallow and less likely to cause choking or aspiration, which is crucial for managing dysphagia in clients with Parkinson's disease.

A. Evaluate for evidence of incontinence. B. Observe for lacerations to the tongue. C. Document details of the seizure activity. D. Observe for prolonged periods of apnoea.

Correct Answer is D

Explanation

Choice A reason: Evaluating for evidence of incontinence is important for understanding the full scope of the seizure's impact on the client. However, it is not the first priority immediately after a seizure. Ensuring the client's airway and breathing status takes precedence.

Choice B reason: Observing for lacerations to the tongue is relevant as it can indicate the severity of the seizure and the potential for airway obstruction. However, the most critical intervention immediately after the seizure is to assess the client's breathing and ensure they are not experiencing prolonged apnoea.

Choice C reason: Documenting the details of the seizure activity is necessary for medical records and future treatment planning. While it is important, it is not the immediate priority. The nurse must first ensure the client's safety and physiological stability.

Choice D reason: Observing for prolonged periods of apnoea is the most urgent intervention. Apnoea, or a pause in breathing, can lead to hypoxia and other serious complications if not addressed immediately. Ensuring that the client is breathing properly is the top priority after a seizure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include in this client's plan of care?

Correct Answer is D

Explanation

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client with Crohn's disease is admitted to the medical unit with a three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first?

The nurse is teaching a client with gastritis about self-management. Which statement made by the client should the nurse recognize as needing additional education?

During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Which statement by a client with systemic lupus erythematosus (SLE) indicates the best understanding of proper skin care?