A client comes in with complaints of a headache. The client states, "I always wake up with a headache in the morning, but it gets better in a couple hours. I notice that it always gets worse if I cough or sneeze." What action by the nurse is most appropriate?

Administer morphine 10 mg IV every 4 hours for the pain.

Palpate the occipital lymph nodes.

Assess the client's neurological status.

Explain that migraine headaches can last a long time.

Answer and Explanation

The Correct Answer is C

Choice A reason: Morphine treats severe pain but isn’t first-line for headaches worsened by coughing, which may signal increased intracranial pressure. Without neurological assessment, this risks masking symptoms of serious conditions like brain tumors, delaying critical diagnosis and intervention.

Choice B reason: Palpating occipital lymph nodes checks for infection or inflammation, but headaches worsened by coughing or sneezing suggest intracranial issues, not lymphatic ones. This action misses the priority of assessing brain function tied to the client’s specific symptom pattern.

Choice C reason: Neurological assessment, like checking reflexes or pupil response, is vital for morning headaches worsening with coughing, hinting at possible intracranial pressure from masses or bleeds. It’s the most direct step to rule out life-threatening causes promptly.

Choice D reason: Explaining migraines assumes a diagnosis without evidence. Morning headaches improving later, worsened by strain, don’t align with typical migraine patterns, risking misdiagnosis of serious conditions like sinus thrombosis, necessitating neurological evaluation over premature reassurance.

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Correct Answer is B

Explanation

Choice A reason: Ophthalmoscopy checks cranial nerve II (optic), not III, IV, or VI. It visualizes the retina, missing the eye movement control these nerves govern, making it irrelevant to their motor function assessment entirely here fully.
Choice B reason: The 6 cardinal fields test cranial nerves III (eye movement, pupil), IV (superior oblique), and VI (lateral rectus). This single technique evaluates all three by tracking coordinated eye motion, making it the most efficient method accurately here.
Choice C reason: Vibration on eyelids tests sensation, possibly cranial nerve V, not III, IV, or VI. These nerves control eye movement, not sensory input, excluding this from assessing their motor roles in this neurological exam fully here.
Choice D reason: Head turning with hand tracking involves neck muscles and possibly cranial nerve XI, not just III, IV, VI. This dilutes focus on eye-specific movements, making it less precise for these cranial nerves’ assessment entirely here.

A. "Are there any foods that you cannot eat?" B. "What have you eaten in the last 24 hours?" C. "Are any members of your family obese?" D. "How many meals do you eat each day?"

Correct Answer is B

Explanation

Choice A reason: Food restrictions identify allergies or preferences, but not intake patterns. This limits nutritional status insight, missing recent consumption data critical for assessing current health, making it less foundational for this initial evaluation fully here.
Choice B reason: A 24-hour recall details recent intake, offering a snapshot of diet quality and quantity. This directly informs nutritional status, habits, and deficits, making it the most appropriate starting question for a comprehensive assessment accurately here.
Choice C reason: Family obesity history suggests genetic risk, not the client’s nutrition. This indirect data lacks specificity on current intake, rendering it less useful than a direct dietary recall for this nutritional assessment entirely and fully here.
Choice D reason: Meal frequency provides structure, not content or quality. It’s less informative than a 24-hour recall, which captures specifics of what’s eaten, making it secondary for initiating a detailed nutritional evaluation comprehensively here fully.

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A client comes in with complaints of a headache. The client states, "I always wake up with a headache in the morning, but it gets better in a couple hours. I notice that it always gets worse if I cough or sneeze." What action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A client comes in with complaints of a headache. The client states, "I always wake up with a headache in the morning, but it gets better in a couple hours. I notice that it always gets worse if I cough or sneeze." What action by the nurse is most appropriate?