# A pregnant client at 32 weeks reports a severe headache and visual spots. Which instruction should the nurse give?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397171&lang=en  
> language: en  
> subject: Lifestyle Choices  
> category: HPM

## Question

A pregnant client at 32 weeks reports a severe headache and visual spots. Which instruction should the nurse give?

## Option

1. Rest in a dark room and mention it at the next visit.
2. Seek immediate evaluation today. **✔ Correct answer**
3. Increase daily sodium intake.
4. Take an over-the-counter decongestant.

**Correct answer: 2**

## Explanation

Severe headache and visual changes during pregnancy are warning signs that require immediate evaluation for possible preeclampsia or other complications. Waiting until the next visit can delay care. Increasing sodium or taking a decongestant does not address the risk.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Pregnancy warning signs.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Pregnancy warning signs, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Preeclampsia** — A pregnancy complication involving hypertension and possible organ involvement.
- **Visual Changes** — A neurologic warning symptom that can occur with severe pregnancy complications.
- **Prenatal Care** — Health care during pregnancy to monitor maternal and fetal well-being.

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