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    Hesi Med-surg proctored exam (MCPHS University)

    A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?

    Explanation & Rationale

    Rationale: A. Alteration in nutrition related to poor dietary intake: Inadequate nutrition is important to address, especially given the client’s financial concerns, but it is not immediately life-threatening compared to potential neurological complications. B. Alteration in comfort related to motor vehicle collision: Headache, blurred vision, vertigo, and nausea may affect comfort, but prioritizing comfort alone overlooks potential serious complications from a recent head injury. C. Anxiety related to unknown outcome of automobile repairs: Financial or situational anxiety is present, but it does not pose an immediate threat to physical health and is lower priority compared to neurological assessment. D. High risk for injury related to increased intracranial pressure: The combination of neuro symptoms and three weeks post-collision suggests a possible post-concussion syndrome or delayed intracranial complication. Prompt assessment and monitoring for increased intracranial pressure are the priority to prevent serious neurological injury.

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