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 D

Explanation

Choice A rationale

Pregnant women may experience increased iron demands due to expanded blood volume and fetal requirements. However, prescribed prenatal vitamins typically contain sufficient iron to prevent deficiency. Compliance with supplementation reduces the risk for anemia, and pregnancy itself is not an independent factor without nutritional inadequacy. Other physiological conditions, such as menorrhagia or dietary restrictions, can significantly elevate risk factors for iron deficiency anemia.

Choice B rationale

Hypertension does not inherently increase the risk of iron deficiency anemia. Exercise three times a week is unlikely to create significant hematological challenges unless combined with conditions like poor dietary intake or chronic illness. Physical activity does not deplete iron stores unless excessive or accompanied by inappropriate nutrition. This client does not exhibit risk factors as critical as menorrhagia or dietary restrictions for anemia development.

Choice C rationale

Working long hours and consuming a high-carbohydrate diet might affect overall health, but these factors do not directly relate to iron absorption or blood loss. While poor nutritional habits can lead to deficiencies, high carbohydrate intake does not necessarily deplete iron reserves. A vegetarian or restrictive diet lacking iron-rich foods poses a greater risk for developing anemia than carbohydrate consumption alone.

Choice D rationale

Menorrhagia results in excessive blood loss during menstruation, which can deplete iron stores and lead to anemia. A strict vegetarian diet often lacks heme iron, which is more readily absorbed compared to non-heme iron from plant sources. Together, these factors create a dual risk of iron deficiency, emphasizing why this client is the most likely among the options to develop anemia. Nutritional counseling and supplementation are key preventive measures.

A. Constant erythema and warmth in the legs. B. Decreased discomfort when the legs are elevated. C. Discomfort in the legs during exercise that is relieved when the client rests. D. Peripheral pulses are bounding when the legs are in the dependent position.

Correct Answer is C

Explanation

Choice A rationale

Constant erythema and warmth in the legs are indicative of venous insufficiency due to stagnant blood flow. PAD typically presents with cool, pale extremities as a result of reduced arterial perfusion.

Choice B rationale

Discomfort typically worsens when legs are elevated in PAD because elevation further impairs blood flow, causing ischemic pain. Relief is more commonly achieved when the legs are in a dependent position, aiding perfusion.

Choice C rationale

Pain during exercise, termed intermittent claudication, occurs due to insufficient oxygen delivery to muscles. Rest alleviates symptoms as oxygen demand decreases. This hallmark feature distinguishes PAD from other circulatory disorders.

Choice D rationale

Peripheral pulses in PAD are generally diminished or absent, reflecting compromised arterial blood flow. Bounding pulses would suggest conditions such as aortic regurgitation or hyperdynamic states, not PAD.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the plan of care for a group of assigned clients on a hematological unit.The nurse should understand that which of the following clients has an increased risk for developing iron deficiency anemia?

Correct Answer is D

Explanation

The nurse is assessing a client suspected of having peripheral artery disease (PAD) in the legs.Which of the following findings should the nurse expect during the assessment?

Correct Answer is C

Explanation

The nurse is assessing four clients at the neighborhood clinic.Which of these clients should the nurse identify to be at risk for the development of pernicious anemia?

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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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