A Nurse Assesses a Client Who Is Recovering from a Transsphenoidal

question 20

Multiple Choice

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.

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