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 D
Explanation
Choice A rationale
After a total laryngectomy, patients may have difficulty swallowing fluids due to changes in the anatomy of the throat.
Choice B rationale
It is not accurate to say that it is no longer possible for the patient to choke on or aspirate food after a total laryngectomy. While the risk of aspiration is reduced because the airway and digestive tract are separated, the patient can still experience choking on food if it is not properly swallowed.
Choice C rationale
Adding a thickener to liquids can help prevent aspiration, but this is typically more relevant for patients with dysphagia or other swallowing disorders, not specifically for patients post- laryngectomy.
Choice D rationale
Tucking the chin when swallowing, also known as the chin-tuck maneuver, can help prevent aspiration by narrowing the entrance to the airway. This can be a useful technique for patients after a laryngectomy.
Correct Answer is A
Explanation
Choice A rationale
Before administering digoxin, it is crucial to measure the patient’s apical pulse. Digoxin affects the heart rate, and a low pulse could indicate that the dose needs to be adjusted.
Choice B rationale
Offering a light snack is not specifically required before administering digoxin.
Choice C rationale
While it’s always important to monitor a patient’s blood pressure, it’s not specifically required before administering digoxin.
Choice D rationale
Weighing the patient is not specifically required before administering digoxin.
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