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
Stopping aspirin a week before surgery is generally recommended to reduce the risk of bleeding. Aspirin can inhibit platelet aggregation and prolong bleeding time.
Choice B rationale
Taking prescribed blood pressure medication with a sip of water on the day of surgery is usually allowed. However, this can depend on the specific medication and the patient’s health status.
Choice C rationale
Not wearing contact lenses on the day of surgery is a standard preoperative instruction. This is because contact lenses can interfere with anesthesia administration and potentially cause injury to the eyes.
Choice D rationale
A recent cough and runny nose could indicate a respiratory infection. This could potentially increase the risk of complications during surgery and may need to be evaluated further. OK. Let’s go through these questions one by one:
Correct Answer is C
Explanation
Choice A rationale
Performing passive range of motion exercises on the right leg in Buck’s traction may not be appropriate. These exercises involve moving the joint without the patient’s muscles doing the work, which could disrupt the traction.
Choice B rationale
Isometric exercises involve contracting the muscles without moving the joints. While these exercises can be beneficial for maintaining muscle strength, they may not promote mobility.
Choice C rationale
Performing active range-of-motion exercises on the left leg can help promote mobility. These exercises involve the patient moving the joint through its full range of motion, which can help maintain joint flexibility and muscle strength.
Choice D rationale
Log rolling the patient every 2 hours may not be appropriate for a patient in Buck’s traction. This technique involves turning the patient as a unit to prevent twisting and protect the spine, which could disrupt the traction.
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