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 B
Explanation
A. Give the patient access to a video about diabetes. – Incorrect. Educational materials are helpful but should be provided after assessing the patient's current knowledge level.
B. Determine what the patient knows about managing diabetes. – Correct Answer. The first step in teaching is to assess the patient's baseline knowledge to tailor the education to their needs.
C. Establish short-term, realistic goals for the patient. – Incorrect. Goal-setting is important but should come after assessing the patient’s knowledge and readiness to learn.
D. Evaluate the effectiveness of the patient's admission teaching plan. – Incorrect. The nurse should first determine what new information needs to be taught before evaluating previous teaching.
Correct Answer is D
Explanation
A. Bring fresh-cut flowers to cheer the patient up. – Incorrect. Fresh flowers should be avoided due to the risk of fungal or bacterial infections in immunocompromised patients.
B. Take the patient to the cafeteria for meals. – Incorrect. Bone marrow transplant patients are at high risk for infection, and leaving the room increases exposure to pathogens.
C. A cover gown is not necessary when entering the patient’s room. – Incorrect. Depending on the hospital’s isolation precautions, visitors may be required to wear gowns and masks to protect the patient.
D. Do not visit if you have had a recent infection. – Correct Answer. Even mild infections can be life-threatening to patients undergoing a bone marrow transplant, so visitors should stay away if they are unwell.
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