A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?
a. Encourage range-of-motion exercises.
b. Document the finding and monitor the client.
c. Take vital signs, including temperature.
d. Assess pain and administer pain medication.
ANS: 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. Documentation should be done after all assessments are completed and should not be the only action. Although pain medication may be a palliative measure, it is not the most appropriate initial action.
You might also like to view...
A 24-hour urine collection has been ordered at 1030, for a child receiving vanillylmandelic acid (VMA). Urine collection should begin:
1. At 0700. 2. With the child's next void. 3. At bedtime. 4. When the order is noted.
The physician writes an order for Atacand 16 mg. Each tablet contains 8 mg. How many tablets would you administer?
1. 1/2 of a tablet 2. 5 tablets 3. 2 tablets 4. 1/5 of a tablet
A resident brought a pillow from home. Which is correct?
a. The person needs to bring a pillowcase, too. b. The person must use a pillow provided by the nursing center. c. The person has the right to use the pillow. d. The pillow must have a safety check by the maintenance department.
A nurse is working with a pregnant teenager in the prenatal clinic. What would be the most important nursing action to help this teen meet the third-trimester developmental tasks of pregnancy?
1. Reassure the patient that ambivalence is normal. 2. Emphasize the need for good nutrition. 3. Assess the patient for discomforts of pregnancy. 4. Discuss continued education plans.