The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

Ask if the client took any medication to treat the headache.

Refer the client to see an eye specialist.

Obtain the client's blood pressure.

Obtain a full history and physical.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Asking about medication use for headaches provides insights into pain management strategies but does not directly address underlying causes of symptoms. Vision changes and headaches may indicate neurological or cardiovascular issues, which require immediate investigation of vital signs like blood pressure to rule out hypertension or increased intracranial pressure.

Choice B rationale

Referring the client to an eye specialist addresses vision changes but neglects the acute nature of headaches. Hypertension or elevated intracranial pressure can affect both vision and cause headaches, and immediate assessment of these factors through blood pressure is more urgent.

Choice C rationale

Obtaining blood pressure evaluates for hypertension, which can manifest with headaches and visual disturbances due to increased arterial pressure affecting cerebral and ocular vessels. Normal blood pressure ranges are typically 120/80 mmHg. Immediate blood pressure measurement prioritizes acute care and mitigates potentially life-threatening conditions.

Choice D rationale

Obtaining a full history and physical is valuable for comprehensive care but delays immediate assessment of critical symptoms such as visual changes and headaches. Measuring blood pressure provides faster evaluation of acute conditions like hypertensive crisis or stroke risk.

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Correct Answer is A

Explanation

Choice A rationale

Ureteral stones cause severe, colicky pain that radiates to the groin or genital area. The ureter’s narrow anatomy can trap stones, causing obstruction. This obstruction triggers increased intrarenal pressure and ureteral spasms, producing waves of intense pain. Hematuria and urinary urgency with minimal voiding are common due to mucosal irritation or obstruction.

Choice B rationale

While small stones may pass spontaneously, predicting exact timelines is speculative. Passage depends on factors like stone size, location, and hydration. For stones larger than 5 mm, spontaneous passage rates decrease, often requiring intervention. Therefore, giving definite timeframes may misinform patients and delay appropriate care.

Choice C rationale

Bladder stones typically cause suprapubic pain, urinary frequency, and hematuria rather than radiating pain to the thigh or genital area. Bladder irritation may lead to dysuria or cloudy urine, but the described symptoms are more consistent with ureteral obstruction rather than bladder involvement.

Choice D rationale

Some stones do require procedural removal, especially those causing recurrent infections or obstruction. However, initial management includes conservative measures like hydration and pain control, reserving procedures for unresolvable cases. Early procedural focus may unnecessarily alarm the client or overlook noninvasive options.

A. The client is obese and has been exercising for 20 minutes per day twice each week. B. The client has reduced sodium intake from 5 grams per day to 3.5 grams per day. C. The client drinks 1 to 2 glasses of wine with dinner a few nights per week. D. The client has reduced smoking cigarettes from 2 packs per day to 1.5 packs per day.

Correct Answer is A

Explanation

Choice A rationale

Obesity and minimal exercise contribute significantly to hypertension due to increased vascular resistance and poor cardiac health. Recommendations for hypertension management include regular physical activity at least 30 minutes daily, five times per week. Current exercise efforts are insufficient, indicating a need for intervention to optimize blood pressure reduction.

Choice B rationale

Sodium intake reduction to 3.5 grams daily is an improvement but still exceeds the recommended limit of 2.3 grams. Excess sodium contributes to hypertension by increasing fluid retention and vascular resistance, though this change alone does not prioritize follow-up over sedentary behavior, which has a larger impact.

Choice C rationale

Alcohol consumption can elevate blood pressure by affecting vascular tone and increasing sympathetic nervous system activity. While 1-2 glasses per day may be within moderation, prioritizing increased physical activity would have a greater benefit on hypertension management than reducing alcohol intake alone.

Choice D rationale

Reducing cigarette smoking from 2 packs to 1.5 packs per day lowers nicotine exposure but still significantly contributes to hypertension through vasoconstriction and arterial damage. Exercise intervention is more impactful for cardiovascular health and blood pressure management in this context.

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The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

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Correct Answer is A

Explanation

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