A patient makes an appointment to see a primary care practitioner for recurrent severe headaches. Which instruction by the nurse will help gather the best additional data before the appointment?

"Try relaxation and warm moist compresses for your headaches and document your response."

"Keep a diary of your headaches, recording symptoms, timing, and headache triggers."

"Call and come in the next time you have a headache so you can be examined."

"Keep track of how many headaches you have before you come in."

Answer and Explanation

The Correct Answer is B

Choice A reason: "Try relaxation and warm moist compresses for your headaches and document your response." is not the best instruction by the nurse to gather additional data before the appointment. It is a suggestion for self-care and pain relief, but it does not provide any information about the cause, type, or severity of the headaches.

Choice B reason: "Keep a diary of your headaches, recording symptoms, timing, and headache triggers." is the best instruction by the nurse to gather additional data before the appointment. It is a useful tool for collecting objective and subjective data about the headaches, such as their frequency, duration, intensity, location, quality, associated symptoms, and precipitating factors. This can help the primary care practitioner to diagnose the type of headache, such as migraine, tension, or cluster, and prescribe the appropriate treatment.

Choice C reason: "Call and come in the next time you have a headache so you can be examined." is not the best instruction by the nurse to gather additional data before the appointment. It is a suggestion for urgent care, but it does not provide any information about the history, pattern, or characteristics of the headaches.

Choice D reason: "Keep track of how many headaches you have before you come in." is not the best instruction by the nurse to gather additional data before the appointment. It is a simple measure of the quantity of the headaches, but it does not provide any information about the quality, severity, or triggers of the headaches.

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Correct Answer is D

Explanation

Choice A reason: This is not a correct explanation for the large number of leukemic white cells. Leukemic white cells are abnormal white blood cells that do not function properly. They do not attempt to take over the function of the abnormal white blood cells, but rather crowd out the normal ones.

Choice B reason: This is also not a correct explanation for the large number of leukemic white cells. Leukemic white cells do not help to protect against infection, but rather increase the risk of infection. They impair the immune system's ability to fight off bacteria, viruses, and other pathogens.

Choice C reason: This is a partially correct explanation for the large number of leukemic white cells. Leukemic white cells are larger in size than normal white blood cells, and they can clog the bone marrow. This can interfere with the production of other blood cells, such as red blood cells and platelets. However, this is not the only reason for the large number of leukemic white cells.

Choice D reason: This is the best explanation for the large number of leukemic white cells. Leukemic white cells are not as effective as normal white cells to protect against infection, because they are immature and dysfunctional. They do not respond to signals from the immune system, and they do not recognize or destroy foreign invaders. They also prevent the normal white cells from doing their job.

A. Notify the health care provider of the patient's status. B. Assess patient for tight clothing around the waist or a full bladder. C. Review the medication administration record for an antihypertensive order. D. Initiate oxygen via a nasal cannula and elevate patient's legs.

Correct Answer is B

Explanation

Choice A reason: Notifying the health care provider of the patient's status is an important action, but not the first priority. The nurse should first assess the patient for any possible triggers of the autonomic dysreflexia, which is a life-threatening condition that occurs in patients with spinal cord injury above the level of T6. It is characterized by a sudden and severe increase in blood pressure, flushing, sweating, headache, and blurred vision.

Choice B reason: Assessing patient for tight clothing around the waist or a full bladder is the first priority action. These are common triggers of autonomic dysreflexia, which cause irritation or stimulation of the nerves below the level of injury. The nurse should remove any tight clothing, catheterize the patient if needed, or perform a bowel evacuation to relieve the pressure and prevent further complications.

Choice C reason: Reviewing the medication administration record for an antihypertensive order is a secondary action, after identifying and removing the trigger of autonomic dysreflexia. The nurse should administer the prescribed antihypertensive medication, such as nifedipine or nitroglycerin, to lower the blood pressure and prevent stroke, seizure, or cardiac arrest.

Choice D reason: Initiating oxygen via a nasal cannula and elevating patient's legs is not an appropriate action for a patient with autonomic dysreflexia. Oxygen therapy is not indicated for this condition, unless the patient has hypoxia or respiratory distress. Elevating the patient's legs can worsen the blood pressure by increasing the venous return and the cardiac output. The nurse should keep the patient in a sitting position to promote the blood flow to the lower extremities and reduce the blood pressure.

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A patient makes an appointment to see a primary care practitioner for recurrent severe headaches. Which instruction by the nurse will help gather the best additional data before the appointment?

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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