A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following
Questions should the nurse include in the assessment?
“Have you experienced any nausea or vomiting with your headache?”
“Are the lights in this room bothering you?”
“Have you noticed any confusion or clouded thinking?”
“Did you feel weak before the headache started or do you feel 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 in assessing the severity of the migraine and planning appropriate interventions.
Choice B rationale
Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.
Choice C rationale
While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.
Choice D rationale
Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Nystagmus, which is involuntary eye movement, is not a common adverse effect of a platelet transfusion.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with platelet transfusions.
Choice C rationale
Chills can be an adverse effect of a platelet transfusion. This could be a sign of a reaction to the transfusion, such as an allergic reaction or a febrile non-hemolytic transfusion reaction.
Choice D rationale
Hypothermia is not a common adverse effect of a platelet transfusion.
Correct Answer is B
Explanation
Choice A rationale
While swelling in the legs can be a side effect of some medications, it is not a measure of the effectiveness of sertraline. Sertraline is an antidepressant, and its effectiveness would be measured by improvements in mood and behavior.
Choice B rationale
An improvement in mood is a key indicator that the sertraline is effective. Sertraline is a selective serotonin reuptake inhibitor (SSRI) used to treat depression and other mood disorders. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance.
Choice C rationale
While it’s important to monitor blood pressure in patients taking any medication, a blood pressure within the expected range is not specifically an indication of the effectiveness of sertraline.
Choice D rationale
Weight loss is not a primary indicator of the effectiveness of sertraline. While some patients may experience weight changes while taking this medication, it is not a measure of its effectiveness in treating depression or other mood disorders.
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