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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Definitions:

Base

The fundamental component or main ingredient in a mixture, formula, or system.

Decimal Places

The number of digits to the right of the decimal point in a number, significant in precision of measurements and calculations.

Percent Increase

The ratio of the increase in value to the original value, expressed as a percentage.

Base Value

The initial point of reference for measuring changes or calculations, such as a starting level in financial indices or a fixed value in property assessments.