A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?
Refer the family to a chronic pain support group.
Request a change in medication from the provider.
Review the child's electronic pain diary.
Set up an appointment with the school nurse.
The Correct Answer is C
A. Referring the family to a chronic pain support group may be beneficial but does not address the immediate need to assess the child's current condition and management.
B. Requesting a change in medication from the provider may be necessary but should be based on a thorough assessment, including reviewing the child's pain diary.
C. Reviewing the child's electronic pain diary allows the nurse to gather important information about the frequency, severity, triggers, and effectiveness of current interventions for migraine headaches, guiding further assessment and management.
D. While involving the school nurse may be part of the child's care plan, it does not address the immediate need to assess the child's current condition and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This task pertains more to secondary prevention, which aims to detect and treat HIV early through screenings and interventions.
B. This task is related to primary prevention, which aims to prevent HIV transmission through education and immunizations.
C. Tertiary prevention focuses on managing and reducing the impact of a disease or condition to prevent complications and promote quality of life. Using an electronic
messaging system to remind clients to take medications aligns with tertiary prevention by helping to manage HIV and prevent disease progression.
D. This task is more aligned with primary prevention, focusing on promoting healthy behaviors to prevent HIV transmission and disease development.
Correct Answer is C
Explanation
A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.
B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.
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