Practice Question
A AS-year-old patient reports daily headaches that have gradually worsened over the past 3 months. The patient states that over-the-counter analgesics "don't help anymore." During the assessment, the nurse notes that the patient's pupils are unequal and the left arm drifts downward when raised. Which nursing action is most appropriate?
Answer Choices:
Correct Answer:
Notify the health care provider immediately and prepare the patient for diagnostic imaging.
Rationale:
🔹 The combination of progressively worsening headaches over months plus neurologic deficits (unequal pupils and unilateral arm drift) suggests a focal intracranial lesion or acute neurologic event.
🔹 Unequal pupils and a drifting left arm indicate focal neurologic impairment, possibly from stroke, brain tumor, hemorrhage, or increased intracranial pressure.
🔹 These findings require urgent evaluation with diagnostic imaging (typically CT or MRI of the head) to identify the cause and prevent further neurologic damage.
🔹 The nurse’s priority is rapid recognition and escalation, notifying the provider immediately rather than delaying care with symptomatic treatment alone.
🔹 Timely imaging and intervention can be critical to preserving neurologic function and reducing the risk of permanent disability or death.
Administer an as-needed oral analgesic and reassess pain in 30 minutes
🔹 Giving an oral analgesic addresses only the symptom of pain and ignores the concerning neurologic signs such as unequal pupils and unilateral arm drift.
🔹 This approach may mask worsening symptoms, potentially delaying recognition of a life-threatening intracranial process.
🔹 Headaches associated with focal neurologic deficits should never be managed with routine PRN analgesia alone.
🔹 Reassessing pain in 30 minutes would waste critical time, during which neurologic damage could progress or become irreversible.
🔹 Because the priority is urgent diagnostic evaluation, this option is unsafe and inappropriate.
Reassure the patient and recommend rest and hydration
🔹 While benign tension headaches may improve with rest and hydration, this patient’s presentation is not consistent with a simple, benign headache.
🔹 The presence of unequal pupils and motor deficit (arm drift) is highly concerning for serious neurologic pathology, not dehydration or stress alone.
🔹 Providing reassurance without urgent evaluation could lead to a dangerous delay in diagnosing conditions like intracranial hemorrhage, mass, or stroke.
🔹 Rest and hydration do not treat structural or vascular brain lesions, which require immediate medical assessment.
🔹 Thus, this response fails to address the red-flag signs and is inappropriate for the severity of the findings.
Document and instruct the patient to keep a headache diary
🔹 A headache diary may be helpful for chronic, stable headaches without neurologic deficits, to track triggers, frequency, and response to treatment.
🔹 In this scenario, symptoms have gradually worsened and are now accompanied by focal neurologic signs, which is a danger sign.
🔹 Asking the patient to wait another week while documenting headaches postpones necessary urgent diagnostic workup.
🔹 Delaying imaging in the setting of neurologic changes increases the risk of neurologic deterioration and missed opportunities for early intervention.
🔹 Therefore, this action is unsafe and inadequate, as it fails to treat the presentation as a potential neurologic emergency.
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Custom- 2201 FA25 Unit 4 Exam-South LA CC Lafayette RN
31 Questions
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- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Adult Health
- Answer Choices: 4