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 ["B","C"]
Explanation
A. Turn the client to the side is the correct action to prevent aspiration, but restraining the client is not appropriate. Restraint can cause injury and should never be used during a seizure. The client should be allowed to move freely during the seizure, and positioning them on their side helps maintain an open airway and prevent aspiration.
B. Time the duration of the seizure is essential for monitoring the length of the seizure. This helps the nurse determine if the seizure is prolonged or if medical intervention is necessary.
C. Administer supplemental oxygen to the client is appropriate if the client is experiencing apnea or breathing difficulties during the seizure. The nurse should ensure the oxygen equipment is ready and functioning to provide supplemental oxygen if needed.
D. Placing a tongue depressor in the client's mouth is not recommended during a seizure. This can cause injury to the client’s mouth, teeth, or airway and does not prevent biting the tongue. Instead, the nurse should focus on protecting the client's airway and preventing aspiration.
Correct Answer is B
Explanation
A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.
B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.
C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.
D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.
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