A client with a history of migraines comes to a clinic with a throbbing headache. What Questions should the nurse include in the assessment?
“Have you experienced any nausea or vomiting with your headache?”
“Are the lights in here bothering you?”
“Have you noticed any confusion or clouded thinking?”
“Have you smelled anything unusual or are you currently smelling anything strange?”
“Did you feel weak before the headache started or are you feeling weak now?”
The Correct Answer is A
Choice A rationale
Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm a diagnosis of a migraine.
Choice B rationale
Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the question “Are the lights in here bothering you?” is less specific to migraines as it could be indicative of several other conditions as well.
Choice C rationale
While confusion or clouded thinking can occur with migraines, it is not as common as other symptoms such as nausea, vomiting, and sensitivity to light.
Choice D rationale
Unusual smells, known as olfactory hallucinations, are not typically associated with migraines. They are more commonly associated with conditions such as epilepsy.
Choice E rationale
Weakness before the headache started or currently feeling weak now is not a typical symptom of migraines. It could be indicative of a more serious condition, such as a stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Oxycodone is an opioid medication, not a nonopioid analgesic. It is used for the relief of moderate to severe pain but has a high potential for addiction and dependence.
Choice B rationale
Ibuprofen is a nonopioid analgesic. It belongs to a class of drugs known as nonsteroidal anti- inflammatory drugs (NSAIDs) and is commonly used to relieve pain, reduce inflammation, and lower fever.
Choice C rationale
Fentanyl is a potent opioid pain medication. It is not a nonopioid analgesic. It is used for managing severe pain, often in people who have built up a resistance to other opioids.
Choice D rationale
Acetaminophen is a nonopioid analgesic. It is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations, and to reduce fever.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Pupillary dilation can be a sign of increased intracranial pressure, which could be a result of a traumatic brain injury following a motor vehicle accident. It’s important to assess for this symptom as it may indicate a serious condition that requires immediate medical attention.
Choice B rationale
Persistent headache is a common symptom following a head injury and can be a sign of a concussion or more serious brain injury. It’s crucial to monitor for this symptom as it can provide important information about the patient’s condition.
Choice C rationale
Presence of hand tremors is not typically associated with a head injury from a motor vehicle accident. While tremors can be a symptom of various neurological conditions, they are not commonly seen immediately after a traumatic head injury.
Choice D rationale
Difficulty waking can be a sign of a serious head injury. It could indicate a concussion or other type of traumatic brain injury. This symptom should be closely monitored as it may require immediate medical intervention.
Choice E rationale
Foot drop is not typically a symptom observed immediately after a motor vehicle accident. It’s more commonly associated with peripheral nerve conditions or stroke, rather than a head injury.
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