A nurse is assessing a client who reports a severe headache. Which of the following findings should the nurse recognize as red flag symptoms requiring immediate evaluation? (Select All that Apply.)
Recent head injury
Confusion
Sudden onset
Accompanied by neck stiffness
Pain relieved with rest
Correct Answer : A,B,C,D
Rationale:
A. A severe headache following trauma may indicate a subdural or epidural hematoma, intracranial hemorrhage, or other serious brain injury. Any new or worsening headache after a head injury warrants immediate evaluation.
B. Altered mental status, including confusion, disorientation, or decreased level of consciousness, can signal increased intracranial pressure, stroke, infection, or other neurological emergencies. This is considered a red flag symptom.
C. A sudden, severe “thunderclap” headache reaching maximum intensity within seconds to minutes can indicate subarachnoid hemorrhage or other vascular emergencies. Rapid onset headaches should be treated as urgent.
D. Neck stiffness or rigidity, especially when associated with headache, may suggest meningitis or subarachnoid hemorrhage. This combination requires immediate assessment and intervention.
E. Headaches that improve with rest are generally tension-type headaches or benign causes and are not considered red flag symptoms. While they may still require evaluation, they do not indicate an urgent or emergent condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Blood pressure is objective data because it is measurable, observable, and quantifiable. The nurse can obtain this information using a blood pressure cuff and verify it independently. Objective data are considered factual and can be used to track changes over time or compare against established norms. While critical for patient care, it does not reflect the patient’s personal experience or perception.
B. Respiratory rate is also objective data because it can be counted and observed. It provides a concrete measure of physiological function and is not influenced by the patient’s subjective feelings. Objective data like vital signs are crucial for detecting trends, assessing baseline health, and identifying early signs of deterioration.
C. The patient reporting feeling nausea is subjective data, meaning it is based on the patient’s personal experience and cannot be directly measured by the nurse. Subjective data include symptoms such as pain, fatigue, dizziness, anxiety, or nausea. This type of information is essential for understanding the patient’s perception of illness, guiding interventions, and planning individualized care. Without eliciting subjective data through careful interviewing, a nurse might miss symptoms that are not apparent through objective measurements alone.
Correct Answer is ["0.6"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 30 mg, Concentration = 50 mg/1 mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 30 ÷ 50
Step 4: Calculate
= 0.6 mL
Step 5: Round to the nearest tenth
≈ 0.6 mL
Final Answer: 0.6
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