The nurse is caring for a client who experiences migraines and reports seeing light flashes. The nurse should recognize this information as which of the following phases of a migraine?
Postdrome
Premonitory
Headache
Aura
The Correct Answer is D
A. The postdrome phase occurs after the headache subsides. During this phase, the client may experience fatigue, mood changes, or mild head discomfort, but it does not include visual disturbances like light flashes.
B. The premonitory phase refers to early warning signs that occur before the onset of the migraine headache, such as fatigue, irritability, or neck stiffness, but not typically visual disturbances like light flashes.
C. The headache phase is when the migraine pain is most severe. The client’s description of seeing light flashes occurs before the pain phase, so this would not be considered the headache phase.
D. The aura phase is characterized by neurological symptoms that occur just before or during the onset of a migraine, and it can include visual disturbances such as light flashes, blind spots, or zigzag lines. This phase can last from a few minutes to an hour and usually precedes the headache phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Methimazole (Tapazole) 15 mg, PO, now and every 4 hours is an appropriate treatment for thyroid storm. Methimazole is an antithyroid medication that inhibits the synthesis of thyroid hormones and helps control the symptoms of thyroid storm.
B. Applying humidified oxygen as needed is appropriate because clients in thyroid storm can develop respiratory distress due to high metabolic demands. Providing humidified oxygen can help maintain adequate oxygenation.
C. Aspirin is contraindicated in thyroid storm. It can increase the release of thyroid hormones from the thyroid gland and may also increase the risk of severe complications like bleeding. Furthermore, aspirin can interfere with the binding of thyroid hormones to proteins, exacerbating the condition. Instead, acetaminophen (Tylenol) should be used to reduce fever in thyroid storm.
D. This is an appropriate intervention to manage hyperthermia, which is a common symptom of thyroid storm. A hypothermia mattress can help reduce the client's elevated body temperature in a controlled manner
Correct Answer is A
Explanation
A. The priority for treating delirium is to identify and address the underlying cause. Delirium is often a symptom of an acute condition such as infection, metabolic disturbances, medication side effects, or other physical issues. Treating the root cause of delirium can help resolve the condition more effectively.
B. While creating a calm, quiet environment can help reduce confusion and agitation, it is not the most critical aspect of treatment. The main focus should be on addressing the cause of the delirium.
C. Reorienting the client is important for safety and reducing confusion, but it will not be sufficient to resolve the delirium if the underlying cause is not addressed. Reorientation is a supportive measure, not the priority intervention.
D. Although monitoring nutrition is important for overall health, it is not the first priority in treating delirium unless malnutrition is identified as a contributing factor to the delirium.
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