A client with a history of hypertension reports a sudden, severe headache and blurred vision. What is the nurse's priority action?
Administer antihypertensive medication as prescribed
Check the client’s blood pressure
Place the client in a quiet environment
Notify the provider about the client’s symptoms
The Correct Answer is B
Choice A reason: Administering antihypertensive medication is important, but it should not be the first step without confirming the client’s current blood pressure. Giving medication without assessment could lead to inappropriate dosing or complications such as hypotension.
Choice B reason: The priority is to check the client’s blood pressure because sudden severe headache and blurred vision are hallmark signs of hypertensive crisis or possible hypertensive encephalopathy. Immediate measurement provides critical data to guide urgent interventions and prevent complications such as stroke or organ damage. This assessment establishes the severity of the situation and directs subsequent actions.
Choice C reason: Placing the client in a quiet environment may help reduce stimulation and stress, but it does not address the underlying acute physiological risk. It is supportive but not the priority intervention.
Choice D reason: Notifying the provider is necessary once the nurse has objective data to report. Without measuring blood pressure first, the nurse cannot provide accurate information to guide urgent medical decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Absent bowel sounds for 12 hours postoperatively may indicate delayed gastrointestinal motility, but this is not immediately life-threatening. It requires monitoring and intervention but does not pose the same acute risk as electrolyte imbalance.
Choice B reason: Edema in heart failure indicates fluid retention and worsening disease, but 2+ edema is a chronic issue rather than an immediate emergency. This client requires ongoing management but is not the highest priority at shift start.
Choice C reason: Elevated potassium in renal failure is a critical emergency because hyperkalemia can cause life-threatening cardiac arrhythmias. Dialysis is urgently needed to remove excess potassium and stabilize cardiac function. This client must be assessed first to prevent sudden cardiac arrest.
Choice D reason: Oxygen saturation of 92% in pneumonia indicates mild hypoxemia. While this requires intervention such as supplemental oxygen, it is less immediately dangerous compared to hyperkalemia, which can cause fatal arrhythmias within minutes.
Correct Answer is B
Explanation
Choice A reason: Ignoring the issue abdicates responsibility and allows errors to persist. Situational leadership requires adapting to the needs of the team and addressing barriers to performance. Failure to act compromises patient safety and team effectiveness.
Choice B reason: Assessing challenges and adapting leadership style demonstrates situational leadership because it tailors interventions to the team’s needs. The manager may provide coaching, mentoring, or directive support depending on staff readiness. This approach improves communication, reduces errors, and fosters growth. It reflects flexibility and responsiveness, which are hallmarks of situational leadership.
Choice C reason: Assigning independent study places responsibility solely on staff without guidance. While self-learning is valuable, it does not address systemic issues or provide structured support. Situational leadership emphasizes adapting the leader’s approach, not delegating responsibility entirely.
Choice D reason: Mandating a tool without staff input is authoritarian and may lead to resistance. Situational leadership involves engaging staff, assessing readiness, and providing appropriate support. Imposing solutions without collaboration undermines morale and may not resolve the underlying communication problems.
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