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 ["B","C","D","E"]
Explanation
Choice A Reason:
Light sensitivity is incorrect. Light sensitivity (photophobia) is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur as a secondary symptom due to other neurological disturbances or increased intracranial pressure.
Choice B Reason:
Loss of consciousness is correct. Loss of consciousness is a common manifestation of a ruptured cerebral aneurysm, particularly if the bleeding leads to significant brain injury or compression of vital brain structures.
Choice C Reason:
A dilated pupil is correct. A dilated pupil (mydriasis) may occur as a result of compression of the oculomotor nerve (cranial nerve III) by the expanding hematoma or increased intracranial pressure following a ruptured cerebral aneurysm.
Choice D Reason:
Visual disturbances is correct. Visual disturbances, such as blurred vision, double vision (diplopia), or loss of vision, may occur due to compression of the optic nerve or damage to visual pathways as a result of the hemorrhage.
Choice E Reason:
Nausea and vomiting is correct. Nausea and vomiting are common symptoms associated with a ruptured cerebral aneurysm, often due to irritation of the meninges and increased intracranial pressure resulting from the bleeding.
Choice F Reason:
Numbness on one side of the face is incorrect. Numbness on one side of the face is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur if the hemorrhage affects specific regions of the brain responsible for sensation or if there is associated compression of cranial nerves.
Correct Answer is B
Explanation
Choice A Reason:
Nutritional therapy is not appropriate. While nutritional therapy may be involved in assessing the client's overall nutritional status and dietary needs, it may not specifically address the swallowing difficulty associated with Parkinson's disease.
Choice B Reason:
Speech therapy is appropriate. Speech therapy, also known as speech-language pathology, plays a crucial role in assessing and managing dysphagia. Speech therapists can evaluate the client's swallowing function and provide interventions to improve swallowing safety and efficiency.
Choice C Reason:
Occupational therapy is incorrect. Occupational therapy focuses on helping individuals engage in meaningful activities of daily living. While occupational therapists may play a role in dysphagia management, speech therapy is typically the primary discipline involved in addressing swallowing difficulties.
Choice D Reason:
Respiratory therapy: Respiratory therapy primarily focuses on evaluating and managing respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), and ventilator support. While dysphagia can sometimes lead to aspiration pneumonia and respiratory complications, respiratory therapists are not typically involved in the assessment and management of dysphagia itself.
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