A client who had a trans-sphenoidal hypophysectomy 2 days ago now has nuchal rigidity. Which is the nurse's priority action?
a. Have the client do active range-of-motion exercises for the neck.
b. Document the finding and monitor the client.
c. Take the client's temperature and other vital signs.
d. Assess using a pain scale and administer pain medication.
C
Nuchal rigidity is a major manifestation of meningitis, a potential postoperative complication associated with this surgery. Meningitis is an infection; usually the client will also have a fever and tachycardia. Range-of-motion exercises are inappropriate because meningitis is a possibility. Although pain medication may be a palliative measure, it is not the most appropriate initial action. Documentation should be done after all assessments are completed and should not be the only action.
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