The nurse is providing care to a patient with a migraine headache. What action should the nurse take?
Provide a dark quiet environment
Eliminate all caffeine from the patient's diet
Monitor for cognitive impairment
Medicate with opioids
The Correct Answer is A
A. Providing a dark, quiet environment is an appropriate intervention for a client with a migraine headache. Migraines are often aggravated by bright lights and loud noises, so creating a calm, low-stimulation environment can help alleviate symptoms.
B. While caffeine can be a trigger for some individuals with migraines, it is not necessary to eliminate all caffeine. In fact, caffeine is sometimes included in medications for migraines to enhance their effectiveness.
C. Cognitive impairment is not a typical concern for migraines unless the headache is severe or prolonged. Monitoring for cognitive impairment would not be the primary action in this scenario.
D. Opioids are not recommended for the treatment of migraines due to their potential for abuse and side effects. NSAIDs, triptans, and other specific migraine treatments are preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Kernig's sign is positive when there is pain and resistance to extending the leg at the knee when the hip is flexed, and Brudzinski's sign is positive when the client involuntarily flexes their knees and hips when the neck is flexed. These are both signs of meningeal irritation, which is characteristic of meningitis.
B. The patellar reflex is a deep tendon reflex that assesses the function of the L2-L4 spinal nerves. It is not specific to meningitis and would not be a primary indicator.
C. The pupillary reflex assesses the response of the pupils to light and is not specific to meningitis. It can be affected by various neurological conditions, but it is not a primary sign of meningitis.
D. Blumberg's sign is associated with peritonitis and indicates rebound tenderness in the abdomen. It is not related to meningitis, which affects the central nervous system rather than the abdominal cavity.
Correct Answer is C
Explanation
A. A thrombotic stroke is typically caused by a blood clot that forms in an artery supplying blood to the brain, usually due to atherosclerosis. While it is a possible cause of stroke, it is not the most likely in this patient with atrial fibrillation.
B. A cerebral aneurysm involves a weakness in the blood vessel wall that can lead to rupture and bleeding, causing a hemorrhagic stroke, but this is not the most common type of stroke in patients with atrial fibrillation.
C. Embolic stroke occurs when a clot or other debris (such as a thrombus) breaks off from a distant part of the body (like the heart in atrial fibrillation) and travels to the brain, blocking a cerebral artery. This is the most common type of stroke in patients with atrial fibrillation due to the formation of clots in the left atrium that can embolize to the brain.
D. Hemorrhagic stroke is caused by the rupture of a blood vessel in the brain, leading to bleeding. It is not the most common type of stroke in patients with atrial fibrillation, though it can occur if there is coagulopathy or anticoagulant therapy.
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