A hospitalized 31-year-old patient with a history of cluster ...

[fagboi]

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.

Question 2

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis?
 
  a. Pupil size
  b. Grip strength
  c. Respiratory effort
  d. Level of consciousness

[shaikhs]

Answer to Question 1

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.

Answer to Question 2

ANS: C
Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.