When admitting a patient who has just arrived on the unit with a severe headache, what should the nurse do first?

a. Complete only basic demographic data before addressing the patient's pain.
b. Medicate the patient for the headache before doing the health history and examination.
c. Take the initial vital signs and then address the headache before completing the health history.
d. Inform the patient that the headache will be treated as soon as the health history is completed.


ANS: C
The patient priority in this situation will be to decrease the pain level because the patient will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacologic or nonpharmacologic therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately.

Nursing

You might also like to view...

When working with a patient with diffuse scleroderma who is exhibiting a "stone face" expression, the nurse should consider which of the following to be a priority nursing diagnosis for this patient?

A) Ineffective tissue perfusion related to tightening of the facial skin B) Activity intolerance related to muscle tightening in lower extremities C) Oral mucous membrane, impaired due to restricted motion of the mouth D) Aspiration, risk related to swallowing impairments

Nursing

The plan of care for a client in hospice care should include:

A) curative treatments. B) control of symptoms. C) postponing death. D) laboratory tests.

Nursing

When a patient is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be

A) Supported with a narrow base B) Counterbalanced by a horizontal adjustment C) Controlled with the upper arm muscles D) Balanced over the center of gravity

Nursing

A panhysterectomy involves removal of

A) uterus, both ovaries, and fallopian tubes. B) uterus only. C) uterus and fallopian tubes. D) ovaries only.

Nursing