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.)

Choice A Reason:

Prodrome is incorrect. The prodrome phase occurs before the onset of the headache and can last for hours to days. During this phase, individuals may experience subtle changes that serve as warning signs of an impending migraine attack. Common prodromal symptoms include fatigue, mood changes, food cravings, increased thirst, and heightened sensitivity to light or sound. Tingling of the face and blind spots in the eyes are not typically associated with the prodrome phase.

Choice B Reason:

Aura is correct. The aura phase of a migraine typically occurs before or during the headache phase and involves neurological symptoms. Aura symptoms can include visual disturbances such as blind spots, zigzag lines, or flashing lights, as well as sensory symptoms like tingling or numbness, often starting in one part of the body and spreading gradually. The tingling of the face and blind spots in the eyes described by the client are consistent with the aura phase of a migraine.

Choice C Reason:

Postdrome is incorrect. The postdrome phase occurs after the headache phase and can last for hours to days. During this phase, individuals may experience lingering symptoms such as fatigue, difficulty concentrating, mood changes, and muscle aches. While some individuals may experience visual disturbances during the postdrome phase, the tingling of the face and blind spots in the eyes described by the client are more characteristic of the aura phase.

Choice D Reason:

Headache is incorrect. The headache phase of a migraine is characterized by moderate to severe throbbing head pain, often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light or sound. While visual disturbances can occur during the headache phase, the tingling of the face and blind spots in the eyes described by the client precede the onset of headache, suggesting the aura phase rather than the headache phase.

Choice A Reason:

Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.

Choice B Reason:

Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.

Choice C Reason:

Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.

Choice D Reason:

Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.