A nurse at a community health clinic is caring for a patient who reports a headache and stiff neck. Which of the following actions should the nurse take first?
Check the patient's blood temperature.
Administer an oral analgesic.
Perform a complete blood count.
Evaluate the patient's neurological status.
The Correct Answer is A
A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.
B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).
C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.
D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.
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Related Questions
Correct Answer is D
Explanation
A. Bradycardia is not a typical sign of hypoglycemia; tachycardia is more common.
B. A fruity odor on the breath is a sign of diabetic ketoacidosis (DKA) (hyperglycemia).
C. Vomiting is more common in hyperglycemia/DKA rather than hypoglycemia.
D. Hypoglycemia presents with cool, clammy skin, sweating, confusion, and tremors due to the release of epinephrine.
Correct Answer is B
Explanation
A. Labeling the mother as "overprotective" is dismissive and non-therapeutic.
B. This response uses therapeutic communication to explore the mother’s concerns without judgment, allowing for education and support.
C. Suggesting home-schooling may reinforce unnecessary restrictions and does not address the concern.
D. Agreeing outright does not help the mother understand that physical activity can be managed safely.
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