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 A

Explanation

A. Platelets 110,000 mm³ – Correct Answer. A low platelet count (thrombocytopenia) increases the risk of bruising and bleeding. Normal platelet range is 150,000–400,000 mm³.

B. WBC 8,000 mm³ – Normal white blood cell count; does not explain increased bruising.

C. Hemoglobin 13.0 g/dL – Normal hemoglobin level; not related to bruising.

D. RBC 4.6 million/mm³ – Normal RBC count; does not indicate a bleeding risk.

A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes. B. Alert and oriented, balanced intake and output, moist mucous membranes. C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable. D. Equal intake and output, denies pain or shortness of breath.

Correct Answer is A

Explanation

A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.

B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.

C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.

D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.

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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

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