A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?
Administering hydromorphone as needed
Distracting the patient with activity
Dimming the lights and reducing stimulation
Initiating a patient-controlled analgesia (PCA) of morphine sulfate .
The Correct Answer is C
Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale
While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale
Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.
Correct Answer is B
Explanation
Choice A rationale
While tremors and decreased mobility are common symptoms of Parkinson’s disease, they are not the most significant impact on a patient’s life. These physical symptoms can be managed with medication and physical therapy.
Choice B rationale
Loss of independence is often the most significant impact on a patient’s life. As the disease progresses, patients may find it increasingly difficult to perform daily activities and may require assistance.
Choice C rationale
Age-related changes can contribute to the progression of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The disease itself, rather than aging, is the primary cause of the symptoms.
Choice D rationale
Neurologic deficits are a result of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The loss of independence that results from these deficits is often more impactful.
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