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 D

Explanation

A. Neutropenic – Used for low WBC count, not platelets.

B. Contact – Used for infections like C. diff or MRSA.

C. Droplet – Used for respiratory illnesses like flu or meningitis.

D. Bleeding – Correct Answer. A low platelet count increases the risk of bleeding, so bleeding precautions are necessary (e.g., soft toothbrush, avoiding IM injections, fall precautions).

A. Loosen the patient's restrictive clothing. B. Open the patient's jaws to insert an oral airway. C. Restrain the patient to prevent injury. D. Place patient in high-Fowler's position.

Correct Answer is A

Explanation

A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.

B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.

C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.

D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.

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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?

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Naxlex Comprehensive Predictor Exams

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