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: Chronic rhinitis affects nasal passages, not oral cancer risk, which ties to tobacco, alcohol, or HPV. This question targets sinus issues, missing key carcinogenic exposures or immunosuppression linked to squamous cell carcinoma in the mouth entirely here.

Choice B reason: Immunosuppressive therapy, like post-transplant drugs, raises oral cancer risk by impairing immune surveillance against HPV or malignant cells. This directly identifies a major risk factor, aligning with health promotion goals to detect oral cancer precursors effectively and accurately.

Choice C reason: Dental visit frequency reflects care access, not specific oral cancer risks like smoking. It’s indirect, missing direct links to immunosuppression or carcinogens, making it less effective for pinpointing etiology in a health promotion context fully here.

Choice D reason: Chewing or swallowing difficulty may signal advanced cancer, not risk factors. It’s a symptom, not a preventive focus, unlike immunosuppression, which precedes disease, reducing its utility for early identification in this educational assessment entirely and clearly.

A. Acute otitis media B. Serous otitis media C. Scarring from previous infections D. Intact tympanic membrane

Correct Answer is D

Explanation

Choice A reason: Acute otitis media shows a red, bulging tympanic membrane due to bacterial infection and pus. A pearly gray, shiny appearance contrasts this, indicating no acute inflammation or fluid, ruling out this active middle ear condition entirely.

Choice B reason: Serous otitis media presents with amber fluid behind a retracted or neutral tympanic membrane, not pearly gray and shiny. This suggests no sterile effusion, distinguishing it from the normal, healthy membrane observed in this inspection clearly.

Choice C reason: Scarring from past infections appears as white, opaque patches on the tympanic membrane, not uniform pearly gray shininess. This finding lacks the irregular, thickened look of scar tissue, pointing to an unscathed membrane instead here.

Choice D reason: A pearly gray, shiny tympanic membrane is normal, reflecting light off an intact, healthy eardrum. This lacks signs of infection or fluid, aligning with standard anatomy where the membrane’s cone of light confirms its integrity 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

A nurse is integrating health promotion education into the assessment of a client's mouth, nose and throat. What interview question is most likely to identify a risk factor for oral cancer?

Correct Answer is B

Explanation

While inspecting the tympanic membrane the nurse notes a pearly gray and shiny appearance. What would this finding indicate?

Correct Answer is D

Explanation

While examining a client's mouth the nurse notes the presence of fasciculations, fine tremors of the client's tongue. How should the nurse best respond to the assessment finding?

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?

A client comes to the clinic with complaints of intense itching to their vaginal area. Upon inspection, the nurse notes swollen labia, erythema to the vaginal mucosa with thick, white discharge. What condition might the nurse suspect?

A client is admitted to the emergency room with a head injury. The client denies a previous history of seizures or head injury. What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

A nurse is planning a personal safety educational session for those who work in a manufacturing plant. Which of the following would be an important risk prevention measure to include regarding hearing?