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: Thrush, a fungal infection from Candida, needs treatment but isn’t immediately urgent unless severe. It’s common in immunocompromised states, manageable with antifungals, lacking the acute, life-threatening potential requiring instant medical escalation in most typical cases here.

Choice B reason: Leukoplakia, white patches in the mouth, may signal precancerous changes linked to oral cancer. Its potential malignancy demands immediate follow-up for biopsy and intervention, distinguishing it as the most urgent diagnosis among these options clearly and critically.

Choice C reason: Gingivitis, gum inflammation, requires dental care but isn’t an immediate medical emergency. It’s reversible with hygiene, not posing the rapid progression risk of leukoplakia, making it less urgent for prompt physician referral in this context fully.

Choice D reason: Canker sores, benign ulcers, heal without intervention and lack systemic threat. Unlike leukoplakia’s cancer risk, they don’t warrant urgent follow-up, remaining a self-limiting condition not necessitating immediate medical escalation beyond routine management here entirely.

A. Impaired judgment. B. Loss of remote memory. C. Tremors accompanying intentional movement. D. Lack of sensation in distal extremities.

Correct Answer is D

Explanation

Choice A reason: Impaired judgment suggests frontal lobe pathology, like dementia, not normal aging. Age-related changes slow processing, not executive function, making this a disease sign, not a typical neurological shift in an 81-year-old fully here.
Choice B reason: Loss of remote memory indicates Alzheimer’s, not normal aging. Aging may slow recall, but long-term memory typically persists, excluding this as an expected age-related change in this neurological assessment entirely and accurately here.
Choice C reason: Intention tremors signal cerebellar disease, like Parkinson’s, not aging. Normal aging may reduce fine motor speed, but not cause action tremors, distinguishing this as pathological, not a standard age-related finding fully here.
Choice D reason: Reduced distal sensation, from nerve conduction slowing, is a common age-related change. Aging thins myelin, impairing peripheral nerves, making this the expected finding in an 81-year-old’s neurological exam accurately and comprehensively here.

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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

The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow up?

Correct Answer is B

Explanation

The nurse is conducting a focused neurologic assessment on an 81-year-old client. What finding below is an age-related neurologic change?

Correct Answer is D

Explanation

The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

A client is seeking medical help due to loss of central vision. What diagnosis might the nurse suspect?

A health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients on how to clean their ears, what action should the nurse recommend?

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?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process in the lungs?