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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Incorrect. Regular insulin should be given before a meal to allow time for onset; giving it after eating delays its effect, increasing hyperglycemia risk.

B. Incorrect. Administering regular insulin after breakfast is inappropriate as it may not align with meal-related glucose spikes.

C. Correct. Regular insulin has an onset of 30 minutes. Administering it at 0730 ensures optimal timing for glucose control when breakfast is eaten at 0800.

D. Incorrect. Giving insulin too early (at 0700) increases the risk of hypoglycemia before food intake.

A. Dextrose 5% in 0,45% sodium chloride IV B. Oral hypoglycemic medications C. Glucocorticoid medications D. 0.9% sodium chloride IV

Correct Answer is D

Explanation

A. Dextrose 5% in 0.45% sodium chloride IV. – Incorrect. Dextrose is given later, after blood glucose drops below 250 mg/dL to prevent hypoglycemia.

B. Oral hypoglycemic medications. – Incorrect. DKA requires IV insulin, not oral medications.

C. Glucocorticoid medications. – Incorrect. Glucocorticoids can worsen hyperglycemia by increasing blood sugar.

D. 0.9% sodium chloride IV. – Correct Answer. Fluid resuscitation with normal saline is the first priority to correct hypovolemia caused by osmotic diuresis in DKA.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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