A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
a. Start the ordered PRN oxygen at 6 L/min.
b. Put a moist hot pack on the patient's neck.
c. Give the ordered PRN acetaminophen (Tylenol).
d. Notify the patient's health care provider immediately.
ANS: A
Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
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