The nurse is working in a college clinic when a student comes in and says, "I think I have a migraine. My head hurts, I cannot stand the bright light, and I feel sick to my stomach." What additional finding is most concerning?
Positive Romberg sign
A subnormal temperature
An ill college roommate
Positive Brudzinski sign
The Correct Answer is D
A. A positive Romberg sign (difficulty maintaining balance with eyes closed) can indicate a neurological issue, but it is not directly associated with a migraine.
B. A subnormal temperature (low body temperature) is not typically associated with migraines and may indicate another issue, but it is not as concerning as other findings.
C. An ill college roommate might suggest a viral illness, but it is not a direct concern for the student’s migraine. Migraines are not contagious, and other signs of illness would be more concerning.
D. Positive Brudzinski sign, which involves involuntary flexion of the hips and knees when the neck is flexed, is indicative of meningeal irritation, a sign of meningitis. This is a medical emergency and much more concerning than the symptoms of a migraine. The student should be further assessed for signs of meningitis, which requires urgent treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vitamin K is the antidote for excessive anticoagulation caused by warfarin. It helps to reverse the effects of warfarin by promoting the synthesis of clotting factors.
B. Naloxone is used to reverse opioid overdose, not related to warfarin or its effects.
C. Disulfiram is used to treat alcohol use disorder by causing unpleasant effects when alcohol is consumed, and is unrelated to warfarin.
D. Protamine is used to reverse the effects of heparin, not warfarin.
Correct Answer is A
Explanation
A. A lumbar herniated disc commonly causes radiating pain down the leg, known as sciatica. This occurs when the herniated disc compresses a nerve root, often causing pain, numbness, tingling, or weakness that radiates down the leg.
B. Headache is not a typical symptom of a lumbar herniated disc. Headaches are generally associated with conditions affecting the head or neck, not the lower back.
C. Difficulty breathing is not associated with a lumbar herniated disc. Breathing problems are typically related to respiratory or cardiac conditions, not issues with the spine.
D. Blurred vision is not a symptom of a lumbar herniated disc. Vision changes are more often related to eye or neurological issues affecting the brain, not the lower back.
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