The nurse assesses a client with a history of migraine headaches. Which clinical manifestation would the nurse identify as an early sign of a migraine with an aura?

Numbness of the fingers

Visual disturbances

Lethargy

Vertigo

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect. Numbness of the fingers is not an early sign of a migraine with an aura, but rather a symptom of a sensory aura, which occurs after the visual aura and before the headache. A sensory aura is a tingling or numb sensation that affects one side of the body, usually the face, arm, or hand.

Choice B reason: This is correct. Visual disturbances are an early sign of a migraine with an aura, which precedes the headache by 10 to 60 minutes. A visual aura is a temporary change in vision, such as seeing flashes, zigzags, blind spots, or shimmering shapes.

Choice C reason: This is incorrect. Lethargy is not an early sign of a migraine with an aura, but rather a symptom of the postdrome phase, which occurs after the headache subsides. The postdrome phase is a period of recovery, where the patient may feel tired, weak, or confused.

Choice D reason: This is incorrect. Vertigo is not an early sign of a migraine with an aura, but rather a symptom of a vestibular migraine, which is a type of migraine that affects the balance and hearing. Vertigo is a sensation of spinning or dizziness that may occur with or without a headache.

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Correct Answer is B

Explanation

Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.

Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.

Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.

Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.

A. Hypoglossal - Cranial Nerve XII B. Trigeminal - Cranial Nerve V C. Facial - Cranial Nerve VII D. Vestibulocochlear - Cranial Nerve VIII

Correct Answer is A

Explanation

Choice A reason: The hypoglossal nerve is responsible for the movement of the tongue. It innervates the muscles of the tongue and allows for speech, swallowing, and chewing.

Choice B reason: The trigeminal nerve is responsible for the sensation and motor function of the face. It innervates the muscles of mastication, the skin of the face, and the mucous membranes of the mouth and nose.

Choice C reason: The facial nerve is responsible for the expression and taste of the face. It innervates the muscles of facial expression, the lacrimal and salivary glands, and the anterior two-thirds of the tongue.

Choice D reason: The vestibulocochlear nerve is responsible for the hearing and balance of the ear. It innervates the cochlea and the vestibular apparatus of the inner ear.

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The nurse assesses a client with a history of migraine headaches. Which clinical manifestation would the nurse identify as an early sign of a migraine with an aura?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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