After determining that the patient has a tension-type headache, which patient statement supports the nurse's finding?

"My nose gets blocked during the headache."

"I feel some pressure on my neck during the headache."

"My eyes hurt during the headache."

“I can see bright lights before the onset of the headache:"

Answer and Explanation

The Correct Answer is B

A. "My nose gets blocked during the headache." Nasal congestion is a common symptom of cluster headaches, which are associated with autonomic symptoms such as tearing, rhinorrhea, and eyelid drooping. This is not characteristic of tension-type headaches.
B. "I feel some pressure on my neck during the headache." Tension-type headaches are often described as a "band-like" pressure or tightness around the head, with muscle tension in the neck and shoulders. The pain is typically bilateral, mild to moderate, and not aggravated by routine activities. Neck muscle stiffness or tenderness is a common feature.
C. "My eyes hurt during the headache." Eye pain is more commonly associated with migraine or cluster headaches. Cluster headaches often present with sharp, stabbing pain behind one eye, while migraines can cause ocular pain with light sensitivity.
D. "I can see bright lights before the onset of the headache." Seeing bright lights or an aura is a hallmark symptom of migraine headaches with aura, not tension-type headaches. Tension headaches do not typically have neurological symptoms like visual disturbances.

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Correct Answer is D

Explanation

A. "The brain is part of the peripheral nervous system." The brain is part of the central nervous system (CNS), not the peripheral nervous system (PNS). The CNS consists of the brain and spinal cord, while the PNS includes cranial and spinal nerves that transmit signals between the CNS and the body.
B. "The peripheral nervous system is responsible for memory." Memory is primarily controlled by the CNS, specifically the brain's hippocampus and cerebral cortex. The PNS is not involved in memory storage or recall; instead, it transmits sensory and motor signals between the body and the CNS.
C. "The spinal cord is part of the peripheral nervous system." The spinal cord is part of the central nervous system (CNS), not the PNS. The PNS consists of nerves that extend from the brain and spinal cord to the rest of the body, including sensory and motor neurons.
D. "The peripheral nervous system regulates the body's response to external stimulus." The PNS is responsible for transmitting sensory information from the environment to the CNS and carrying motor responses back to the body. It includes the somatic nervous system (voluntary control of muscles) and autonomic nervous system (involuntary functions like heart rate and digestion). This makes it essential in responding to external stimuli such as pain, temperature, and pressure.

A. Document the time the seizure began. B. Turn the client's head to the side. C. Check the client's motor strength. D. Loosen the clothing around the client's waist.

Correct Answer is B

Explanation

A. Document the time the seizure began. While timing the seizure is important to assess its duration and guide treatment, airway protection is the priority. The nurse should first position the client’s head to the side to prevent airway obstruction before documenting seizure onset.
B. Turn the client’s head to the side. Turning the client’s head to the side helps prevent aspiration of saliva or vomit and promotes airway patency. During a tonic-clonic seizure, muscle contractions can cause excessive oral secretions, increasing the risk of airway obstruction. Placing the client in a side-lying position is the first priority to maintain breathing and reduce aspiration risk.
C. Check the client's motor strength. Assessing motor strength should be done after the seizure ends, as the client will have involuntary muscle contractions during the seizure. Attempting to check motor function during the seizure could lead to injury to both the client and the nurse.
D. Loosen the clothing around the client's waist. Loosening tight clothing (especially around the neck) can help with breathing, but it is not the first priority. Positioning the client’s head to the side is more critical to prevent airway obstruction before adjusting clothing.

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After determining that the patient has a tension-type headache, which patient statement supports the nurse's finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about the peripheral nervous system. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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