The nurse is assessing a client with a neurologic health problem and discovers a change in the LOC from alert to lethargic. What is the nurse's best action?
A. Perform a complete neurologic assessment
B. Assess the cra
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The nurse is assessing a client with a neurologic health problem and discovers a change in the LOC from alert to lethargic. What is the nurse's best action?
A. Perform a complete neurologic assessment
B. Assess the cranial nerve functions
C. Contact the Rapid Response Team
D. Reassess the client in 30 minutes
C. Contact the rapid response team
The nurse on the neurological acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that Apply.
1. When did you first experience the headache symptoms?
2. Who is the Mayor of Cleveland?
3. What is your health care provider's name?
4. What year and month is this?
5. What is your parent's address?
6. What is the name of this health care facility?
1, 3, 4, 6
What is the priority nursing concern for a client experiencing a migraine headache?
A. Pain
B. Anxiety
C. Hopelessness
D. Risk for brain injury
A. Pain
The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that Apply.
1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided.
2. Drugs such as nitroglycerin and nifedipine should be avoided
3. Abortive therapy is aimed at eliminating the pain during the aura
4. A potential side effect of medications is rebound headache
5. Complementary therapies such as biofeedback and relaxation may be helpful
6. Estrogen therapy should be continued as prescribed by the client's HCP.
1, 2, 3, 4, 5
Estrogen supplements may actually trigger headaches
After a client has a seizure, which actin can the nurse delegate to the UAP?
A. Documenting the seizure
B. Performing neurologic checks
C. Checking the client's vital signs
D. Restraining the client for protection
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