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:

Prothrombin time (PT) is a laboratory test that measures the time it takes for blood to clot is incorrect. While PT may be part of a comprehensive evaluation in some cases, it is not typically the initial diagnostic test performed for a TIA. A TIA is caused by a temporary disruption of blood flow to the brain, often due to an embolus or transient blockage in a cerebral artery, rather than a primary disorder of blood clotting.

Choice B Reason:

Complete blood count (CBC) is incorrect. A complete blood count (CBC) is a common laboratory test that evaluates the cellular components of the blood, including red blood cells, white blood cells, and platelets. While CBC can provide valuable information about hematological conditions such as anemia or thrombocytosis, it is not specific to diagnosing the cause of a TIA. TIA is primarily a vascular event related to transient ischemia in the brain rather than a disorder of blood cell counts.

Choice C Reason:

Computerized tomography angiography (CTA) is appropriate. CTA is a non-invasive imaging test that combines computed tomography (CT) scanning with contrast dye to visualize blood vessels throughout the body, including those in the brain. CTA can help identify any blockages, narrowing, or abnormalities in the blood vessels supplying the brain, which may be contributing to the TIA. It provides detailed images of the blood vessels' structure and can help guide further management and treatment decisions.

Choice D Reason:

Transesophageal echocardiogram (TEE) is inappropriate. Transesophageal echocardiogram (TEE) is an imaging test that provides detailed images of the heart and major blood vessels using sound waves. While TEE may be indicated in some cases of TIA to evaluate for potential cardiac sources of emboli (blood clots), such as atrial fibrillation or cardiac valve abnormalities, it is not typically the first-line diagnostic test performed in the emergency department setting for evaluating a TIA. Initial imaging studies such as CTA or magnetic resonance imaging (MRI) of the brain are usually prioritized to assess for acute changes in cerebral blood flow and potential causes of the TIA.

A. Drooling B. Anhidrosis C. Tremors D. Rigidity

Correct Answer is B

Explanation

Choice A Reason:

Drooling is inappropriate. Drooling, also known as sialorrhea, is a common symptom in Parkinson's disease due to impaired swallowing and reduced control of the muscles involved in saliva production. Anticholinergic medications can exacerbate dry mouth, which may contribute to drooling. However, drooling is not typically a side effect that would be specifically associated with anticholinergic use.

Choice B Reason:

Anhidrosis is appropriate. Anhidrosis refers to the inability to sweat normally. Anticholinergic medications can inhibit sweating by blocking the action of acetylcholine on sweat glands, leading to decreased sweating and potentially causing hyperthermia. Anhidrosis is a potential side effect of anticholinergic agents and should be reported to the healthcare provider due to the risk of overheating.

Choice C Reason:

Tremors is inappropriate. Tremors are a common symptom of Parkinson's disease and are typically not caused by anticholinergic medications. In fact, anticholinergic agents are often prescribed to help reduce tremors in individuals with Parkinson's disease. Tremors would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.

Choice D Reason:

Rigidity is inappropriate. Rigidity, or stiffness of the muscles, is a characteristic symptom of Parkinson's disease resulting from the loss of dopamine-producing neurons in the brain. While anticholinergic medications can help alleviate some symptoms of Parkinson's disease, they are not typically associated with rigidity. Rigidity would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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