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
Explanation
Choice A rationale
Reducing the temperature in the room is not typically a treatment for brain herniation. While it’s important to maintain a comfortable environment for the patient, there’s no evidence to suggest that room temperature has a direct impact on the progression or treatment of brain herniation.
Choice B rationale
Hyperventilating the patient is a possible treatment for brain herniation. Hyperventilation causes vasoconstriction, which can decrease cerebral blood flow and intracranial pressure, potentially relieving the pressure caused by the herniation.
Choice C rationale
Lowering blood pressure is not typically a treatment for brain herniation. While maintaining a stable blood pressure is important in all patients, aggressively lowering blood pressure could potentially decrease cerebral perfusion and worsen the patient’s condition.
Choice D rationale
Decreasing sedation is not typically a treatment for brain herniation. In fact, sedatives might be used to reduce metabolic demands and control agitation in a patient with brain herniation.
Correct Answer is A
Explanation
Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale
While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.
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