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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) Keep the pace of the history moving forward to reduce time: While it's important to be efficient, rushing through the health history can compromise the quality of the information gathered. Older adults may need more time to recall details and respond thoughtfully. Ensuring a thorough and patient approach is essential for obtaining accurate and comprehensive information.
(B) Limit the use of brief screening tools: Brief screening tools can be valuable for identifying specific health issues quickly and efficiently. Limiting their use might lead to missing important information or failing to detect underlying conditions. Using appropriate screening tools helps in capturing relevant data and providing a better overall assessment.
(C) Limit open-ended questions: Open-ended questions are crucial in obtaining detailed and descriptive responses from older adults. Limiting their use could hinder the ability to understand the client’s complete health history and concerns. These questions encourage clients to elaborate on their experiences and provide more nuanced information.
(D) Have the room well-lit with minimal background noise: A well-lit room with minimal background noise creates an environment conducive to effective communication. Older adults might have impaired vision or hearing, so ensuring good lighting and reducing distractions helps them focus and respond more accurately. This strategy enhances the accuracy of the health history and facilitates better interaction between the nurse and client.
Correct Answer is A
Explanation
A) Range of motion: Lateral bending of the spine is a movement used to assess the range of motion (ROM) of the spine, specifically the flexibility and mobility of the thoracolumbar region. By asking the client to perform lateral bends, the nurse can evaluate the extent to which the client can bend sideways and assess any limitations or discomfort in the movement.
B) Diaphragmatic excursion: Diaphragmatic excursion refers to the movement of the diaphragm during respiration and is assessed through techniques like percussion and auscultation of the lungs. Lateral bending of the spine does not provide information about diaphragmatic movement.
C) Spinous processes: The spinous processes of the vertebrae can be palpated to assess alignment and tenderness, but lateral bending does not specifically assess the spinous processes. It focuses more on the overall mobility of the spine.
D) Spinal deformities: While lateral bending can reveal limitations in spinal movement that might suggest underlying spinal deformities, it is not a primary diagnostic tool for identifying specific deformities. Other assessments, such as inspection and palpation of the spine, X-rays, or physical
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