A nurse is caring for a client who has chronic migraine headaches. The client asks the nurse if it could be a cerebral aneurysm. Which of the follow responses should the nurse use?

"If you have a cerebral aneurysm, you would be having seizures."

"If you have a cerebral aneurysm, you will experience nausea and vomiting."

"If you had a cerebral aneurysm, you would have a stiff neck."

"If you have a cerebral aneurysm, you typically will have no symptoms."

Answer and Explanation

The Correct Answer is D

"If you have a cerebral aneurysm, you would be having seizures. “is incorrect because not all cerebral aneurysms cause seizures. Seizures may occur if the aneurysm ruptures and causes bleeding into the brain, but they are not a universal symptom of an unruptured cerebral aneurysm.

Choice B Reason:

"If you have a cerebral aneurysm, you will experience nausea and vomiting. “is incorrect because while headaches, nausea, and vomiting can occur with a ruptured cerebral aneurysm (subarachnoid hemorrhage), they are not necessarily present in all cases, especially with unruptured aneurysms.

Choice C Reason:

"If you had a cerebral aneurysm, you would have a stiff neck." is incorrect because a stiff neck (meningeal irritation) is typically associated with subarachnoid hemorrhage from a ruptured cerebral aneurysm, but it is not always present and is not a definitive symptom of an unruptured aneurysm.

Choice D Reason:

"If you have a cerebral aneurysm, you typically will have no symptoms." Cerebral aneurysms can vary greatly in terms of their presentation and symptoms. While some aneurysms may cause symptoms such as headaches, nausea, vomiting, seizures, or a stiff neck, many cerebral aneurysms are asymptomatic and go unnoticed until they rupture or are incidentally discovered during imaging studies for other reasons.

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Correct Answer is C

Explanation

Choice A Reason:

Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.

Choice B Reason:

Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.

Choice C Reason:

Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.

Choice D Reason:

Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.

A. "Are you having any feelings of depression?" B. "Are you experiencing any sensitivity to light?" C. "Are you feeling any increase in your sexual drive?" D. "Are you experiencing any episodes of 'panic-type' feelings?" E. "Are you experiencing more fatigue as compared to before you had migraines?"

Correct Answer is ["A","D","E"]

Explanation

Choice A Reason:

"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.

Choice B Reason:

"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.

Choice C Reason:

"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.

Choice D Reason:

"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.

Choice E Reason:

"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.

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A nurse is caring for a client who has chronic migraine headaches. The client asks the nurse if it could be a cerebral aneurysm. Which of the follow responses should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury and has absent bowel sounds in the lower abdominal quadrants. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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