What is the expected nursing action for a patient presenting with severe headaches?

Performing a neurological assessment and monitoring vital signs is a crucial first step when a patient presents with severe headaches. This action allows the nurse to gather important information about the patient's neurological status and identify any potential underlying causes that may be contributing to the headache. It is essential to assess the patient for any signs of neurological deficits, such as weakness, changes in consciousness, or abnormalities in coordination, which could indicate a more serious condition such as a hemorrhage or stroke.

Monitoring vital signs is equally important, as changes in blood pressure, heart rate, or temperature can provide further clues to the patient's condition and help guide further treatment decisions. Overall, this approach prioritizes patient safety and allows for timely interventions based on the findings of the assessment.

Other actions may certainly be appropriate later on depending on the assessment's findings, but the immediate nursing responsibility involves thorough evaluation and monitoring to ensure comprehensive care.