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 D
Explanation
Choice A rationale
Osmotic cerebral edema is a condition where water moves from the blood vessels into the brain due to changes in the concentration of particles in the blood. However, this is not the primary cause of cerebral edema in meningitis.
Choice B rationale
While inflammation can contribute to cerebral edema, it is not specific to the brain and does not affect the brain the most. In meningitis, the inflammation is primarily in the meninges, the membranes that cover the brain, and not the whole body.
Choice C rationale
Cerebrospinal fluid (CSF) does flow from the intraventricular space to the interstitial area of the brain, but this is a normal process and does not cause cerebral edema. In meningitis, the inflammation of the meninges can disrupt the normal flow and absorption of CSF, leading to an accumulation of fluid and increased intracranial pressure.
Choice D rationale
In meningitis, the inflammation and immune response to the infection can lead to an increase in the permeability of the blood-brain barrier. This allows fluid and immune cells to enter the brain tissue, leading to cerebral edema. Additionally, the by-products of the pathogen that causes meningitis can directly damage the brain tissue and contribute to the edema.
Correct Answer is A
Explanation
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.
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