A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion.
The nurse should prioritize which of the following actions?
Administering antihypertensive medication as prescribed.
Preparing the client for a lumbar puncture.
Initiating seizure precautions.
Monitoring the client’s blood glucose levels.
The Correct Answer is A
Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion.
These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The left extrapyramidal tract is involved in motor control, but lesions here would not cause right homonymous hemianopia or inability to move the right arm. These symptoms are more indicative of a lesion in the cerebral hemisphere.
Choice B rationale
A lesion in the right cerebral hemisphere would cause left-sided symptoms, not right-sided. The patient’s symptoms are indicative of a lesion in the left cerebral hemisphere.
Choice C rationale
The cerebellum is involved in coordination and balance, not in causing right homonymous hemianopia or inability to move the right arm. These symptoms are more indicative of a lesion in the cerebral hemisphere.
Choice D rationale
A lesion in the left cerebral hemisphere can cause right homonymous hemianopia and inability to move the right arm. This is because the left hemisphere controls the right side of the body and processes visual information from the right visual field.
Correct Answer is D
Explanation
Choice A rationale
Hypokalemia can cause muscle weakness and cramps, but it does not typically lead to severe muscle spasms causing exhaustion. The patient’s symptoms of lethargy and weakness are more likely related to electrolyte imbalances and dehydration rather than muscle spasms.
Choice B rationale
While low potassium levels can affect cellular metabolism, the primary issue here is not glycolysis. The patient’s symptoms are more consistent with dehydration and electrolyte imbalances rather than a metabolic shift to glycolysis.
Choice C rationale
Hypokalemia can cause cells to become hyperpolarized, leading to muscle weakness and decreased reflexes. However, the patient’s symptoms of lethargy and weakness are more likely due to dehydration and electrolyte imbalances rather than cellular hyperpolarization.
Choice D rationale
Hypernatremia, or high sodium levels, can cause cellular dehydration, leading to symptoms such as lethargy and weakness. The patient’s lab results and clinical presentation are consistent with hypernatremia-induced cellular dehydration, which explains his symptoms.
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