A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following questions should the nurse include in the assessment?
(Select All that Apply.)
"Have you had any nausea and vomiting with your headache?"
"Are you bothered by the lights in here?"
"Have you noticed any confused or cloudy thinking?"
"Have you experienced or are you experiencing any strange smells?"
"Did you feel weak before the headache started or do you feel weak now?"
Correct Answer : A,B,D
Choice A Reason:
"Have you had any nausea and vomiting with your headache?": This question is appropriate. Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm the diagnosis of a migraine headache.
Choice B Reason:
"Are you bothered by the lights in here?" This question is appropriate. Sensitivity to light, known as photophobia, is a classic symptom of migraines. Inquiring about light sensitivity can provide additional evidence for the diagnosis.
Choice C Reason:
"Have you noticed any confused or cloudy thinking?". This question is inappropriate. Confusion or cognitive symptoms are not typical of migraines. However, some individuals may experience difficulty concentrating or cognitive symptoms during a migraine aura. This question may help assess for aura symptoms.
Choice D Reason
Have you experienced or are you experiencing any strange smells?" This question is appropriate. Some individuals may experience olfactory hallucinations or sensitivity to odors during a migraine aura. Asking about strange smells can help identify possible aura symptoms.
Choice E Reason:
"Did you feel weak before the headache started or do you feel weak now?" This question is inappropriate. While weakness is not a typical symptom of migraines, some individuals may experience fatigue or muscle weakness during a migraine attack. This question may help assess the overall impact of the headache on the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Vasogenic cerebral edema is appropriate response. Vasogenic cerebral edema occurs due to disruption of the blood-brain barrier (BBB), leading to leakage of fluid and proteins from the blood vessels into the brain parenchyma. This type of cerebral edema is commonly associated with conditions such as brain tumors, abscesses, and ischemic stroke.
Choice B Reason:
Osmotic cerebral edema is inappropriate response. Osmotic cerebral edema occurs when there is an imbalance of osmotic forces across the blood-brain barrier, leading to the movement of water into the brain cells. This type of cerebral edema can result from conditions such as hyponatremia or the administration of hypertonic solutions.
Choice C Reason:
Cellular cerebral edema is inappropriate response. Cellular cerebral edema involves the swelling of brain cells (neurons and glial cells) due to various insults, such as ischemia, hypoxia, or metabolic disturbances. This type of cerebral edema can occur in conditions such as ischemic stroke or traumatic brain injury.
Choice D Reason:
Interstitial cerebral edema is incorrect response. Interstitial cerebral edema involves the accumulation of fluid within the interstitial spaces of the brain tissue. This type of cerebral edema can occur in conditions such as hydrocephalus, where there is obstruction of cerebrospinal fluid (CSF) flow.
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason:
Loss of teeth is not typically considered a direct factor contributing to obstructive sleep apnea. While the presence of teeth may play a role in maintaining the structure of the oral cavity, it is not a primary risk factor for OSA.
Choice B Reason:
Stroke is correct. Individuals who have had a stroke are at increased risk of developing obstructive sleep apnea. Stroke can cause damage to areas of the brain involved in controlling breathing and upper airway function, leading to disruptions in respiratory control during sleep.
Choice C Reason:
Sleepiness is a symptom commonly associated with obstructive sleep apnea rather than a direct contributing factor. Excessive daytime sleepiness is a consequence of disrupted sleep patterns and recurrent episodes of breathing cessation during the night, which are characteristic features of obstructive sleep apnea.
Choice D Reason:
Fatty deposits is correct. Excessive fatty deposits, particularly around the neck and throat, can contribute to the narrowing and collapse of the upper airway during sleep, increasing the risk of obstructive sleep apnea. Obesity is a significant risk factor for OSA due to the accumulation of fat deposits in the upper airway tissues.
Choice E Reason:
Muscle dysfunction is correct. Muscle dysfunction, particularly of the muscles surrounding the upper airway, can impair the ability of these muscles to keep the airway open during sleep. Weakness or dysfunction of these muscles can lead to increased collapsibility of the upper airway, contributing to obstructive sleep apnea.
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