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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.

B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.

C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.

D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."

A. A sensory warning that a seizure is imminent B. A brief loss of consciousness accompanied by staring C. A continuous seizure state in which seizures occur in rapid succession D. A period of sleepiness following the seizure during which arousal is difficult

Correct Answer is A

Explanation

A. An aura is a sensory warning (such as a strange taste, smell, or visual disturbance) that often precedes a seizure, indicating that a seizure is imminent. It is a common experience for individuals with certain types of seizures, such as focal seizures.

B. A brief loss of consciousness accompanied by staring is indicative of absence seizures, not an aura.

C. A continuous seizure state in which seizures occur in rapid succession is known as status epilepticus, a medical emergency.

D. A period of sleepiness following the seizure is called the postictal state, but this is not related to an aura, which occurs before the seizure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Correct Answer is C

Explanation

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?

Correct Answer is A

Explanation

When a client is in the headache stage of a migraine headache, which of the following may help the person cope with this stage? Select all that apply.

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