A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?
Obtain a throat culture specimen.
Perform a complete blood count.
Check the client's temperature.
Administer an oral analgesic.
The Correct Answer is C
A. Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.
C. Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.
D. Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should identify that developing a respiratory infection can cause a myasthenic crisis in a client who has myasthenia gravis. A myasthenic crisis is a sudden worsening of myasthenia gravis symptoms, which can include difficulty breathing and swallowing. Respiratory infections can exacerbate these symptoms and trigger a myasthenic crisis.
Taking too much-prescribed medication, insufficient exercise, and insufficient sleep are not factors that can cause a myasthenic crisis. Taking too much-prescribed medication can cause side effects but would not directly cause a myasthenic crisis. Insufficient exercise and insufficient sleep can worsen overall health but would not directly cause a myasthenic crisis.
Correct Answer is D
Explanation
An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.
The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.
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