A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Choice A reason: Evaluating neurological status is the first action for a client with headache and stiff neck, as these symptoms suggest possible meningitis or other neurological emergencies. Assessing for signs like altered mental status, Kernig’s sign, or Brudzinski’s sign guides urgent diagnosis and treatment to prevent complications like increased intracranial pressure. Choice B reason: Performing a complete blood count is relevant to diagnose infection (e.g., elevated white blood cells in meningitis) but is not the first action. Neurological assessment takes priority to identify life-threatening conditions like meningitis or subarachnoid hemorrhage, which require immediate intervention based on clinical findings. Choice C reason: Administering an oral analgesic may relieve headache but is not the first action. Headache and stiff neck may indicate meningitis, a medical emergency requiring neurological assessment to guide diagnosis and treatment. Pain relief could mask symptoms, delaying critical interventions for a potentially life-threatening condition. Choice D reason: Checking the client’s temperature is important, as fever may suggest infection like meningitis, but it is not the first action. Neurological assessment is prioritized to detect signs of meningeal irritation or increased intracranial pressure, which are critical for timely diagnosis and management of potentially fatal neurological conditions.