A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache?

Tension headache

Migraine headache

Cluster headache

Sinus headache

Answer and Explanation

The Correct Answer is B

A) Tension headache: Tension headaches are typically characterized by a dull, aching pain that feels like a tight band around the head. They are often associated with muscle tension and stress, and they generally do not involve nausea, vomiting, or sensitivity to light and sound, which are more indicative of migraines.
B) Migraine headache: The symptoms described—severe pain rated 10 out of 10, nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia)—are classic signs of a migraine headache. Migraines are often intense and can be accompanied by these additional symptoms, making this the most likely diagnosis.
C) Cluster headache: Cluster headaches are extremely painful and typically occur in cyclical patterns or clusters. They are often unilateral (one-sided) and can cause severe pain, redness of the eye, and nasal congestion. While they can be very painful, they are less commonly associated with nausea, vomiting, and sensitivity to light and sound as described in the scenario.
D) Sinus headache: Sinus headaches are associated with sinusitis and typically involve pain and pressure in the forehead, cheeks, or nose area, often accompanied by nasal congestion. They usually do not present with the intensity of pain, nausea, vomiting, and sensitivity to light and sound seen in migraines.

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Correct Answer is C

Explanation

A. Obtunded: Obtunded describes a state where a person has reduced alertness and is difficult to arouse but can respond to stimuli, such as verbal commands or physical touch. The client’s eyes remain closed and they are unresponsive to all stimuli, which is more severe than obtunded.
B. Stupor: Stupor is a condition where a person is in a near-unconscious state and responds only to vigorous or painful stimuli. Although the client is unresponsive to all stimuli, stupor usually involves some minimal response to pain or other strong stimuli, which doesn’t match the complete unresponsiveness described.
C. Coma: A coma is a profound state of unconsciousness where a person is unresponsive to all stimuli, including verbal, visual, and painful stimuli, and their eyes remain closed. This description matches the client’s condition of being unresponsive and with closed eyes.
D. Lethargy: Lethargy is characterized by excessive drowsiness or a reduced level of consciousness where the individual can be aroused with minimal effort. This state does not accurately describe a client who is unresponsive to all stimuli and whose eyes remain closed.

Correct Answer is "{\"xRanges\":[null,null],\"yRanges\":[null,null]}"

Explanation

Answer: The hot spot in the right lower quadrant that corresponds to this location.

Locate the right anterior superior iliac spine (the bony prominence on the right side of the pelvis). Identify the umbilicus (navel). McBurney's point is roughly one-third of the distance from the anterior superior iliac spine to the umbilicus.

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Naxlex Comprehensive Predictor Exams

Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

Correct Answer is C

Explanation

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[null,null],\"yRanges\":[null,null]}"

Explanation

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