A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Give the ordered PRN acetaminophen (Tylenol).

Start the prescribed PRN 02 at 6 L/min

Put a moist hot pack on the patient's neck.

Notify the patient's health care provider immediately.

Answer and Explanation

The Correct Answer is B

A: "Give the ordered PRN acetaminophen (Tylenol)." Acetaminophen is generally not effective for treating cluster headaches, as these headaches are characterized by severe pain that does not respond well to over-the-counter pain medications. Therefore, administering acetaminophen would not address the immediate need for relief.
B: "Start the prescribed PRN O2 at 6 L/min." Administering oxygen at 6 L/min is a recognized and effective treatment for cluster headaches. Inhaling oxygen can help alleviate the headache by causing vasoconstriction of the dilated cerebral vessels and improving oxygen supply to the brain. This intervention should be prioritized to provide the patient with prompt relief from the acute headache.
C: "Put a moist hot pack on the patient's neck." While applying heat can provide comfort for some types of headaches, it is not effective for cluster headaches. These headaches are often exacerbated by heat and require different management strategies.
D: "Notify the patient's health care provider immediately." Although it may be necessary to inform the healthcare provider about the patient's condition, immediate relief for the cluster headache should take precedence. The nurse can initiate the oxygen therapy first to address the patient's acute pain before considering further interventions or notifications.

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Correct Answer is D

Explanation

A. Sporting accidents. While sports-related injuries, such as those from diving or contact sports, can cause spinal cord injuries (SCIs), they are more common in younger individuals. In older adults, decreased participation in high-risk sports makes this an unlikely primary cause of SCIs.
B. Gunshot wounds. Gunshot wounds can lead to penetrating spinal injuries, but they are not a leading cause of SCIs in individuals aged 65 years and older. SCIs due to violence-related incidents are more common in younger populations.
C. Motor vehicle accidents. Motor vehicle accidents (MVAs) are a leading cause of SCIs in younger adults but are less common than falls in older adults. Age-related changes, such as slower reaction times and decreased coordination, increase the risk of accidents, but falls remain the most frequent cause in this age group.
D. Falls. Falls are the most common cause of spinal cord injuries in adults aged 65 years and older. Age-related osteoporosis, muscle weakness, impaired balance, and reduced vision increase the risk of falls. Older adults are particularly susceptible to vertebral fractures and spinal trauma from even minor falls, making this the leading cause of SCIs in this age group.

A. Examine the client for areas of skin breakdown. B. Place the client in a sitting position. C. Check the client for a fecal impaction. D. Check the client's bladder for distention.

Correct Answer is B

Explanation

A. Examine the client for areas of skin breakdown. Skin breakdown can be a trigger for autonomic dysreflexia (AD) due to noxious stimuli, but assessing the skin is not the priority action. The immediate concern is to lower the client's blood pressure to prevent complications such as stroke or seizures.
B. Place the client in a sitting position. The first priority in autonomic dysreflexia is to place the client in a sitting position (or at least 45 degrees). This promotes blood pooling in the lower extremities and helps reduce dangerously high blood pressure. AD is a medical emergency in clients with spinal cord injuries at T6 or above, requiring immediate intervention.
C. Check the client for a fecal impaction. A fecal impaction is a common cause of AD, but the priority is to first lower the blood pressure before assessing for the trigger. Once the client is positioned appropriately, the nurse can assess for bowel or bladder distention as a potential cause.
D. Check the client’s bladder for distention. A distended bladder is the most common cause of AD, but assessment should be done after positioning the client upright. If urinary retention is identified as the trigger, the nurse should immediately catheterize the client to relieve the obstruction.

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A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

Correct Answer is D

Explanation

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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