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 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."
Correct Answer is B
Explanation
A. 700: This is incorrect, check the calculation in choice D rationale
B. 660: This is incorrect, check the calculation in choice D rationale
C. 900: This is incorrect, check the calculation in choice D rationale
D. To calculate the total intake, we need to convert all fluid measurements to milliliters (mL) and then add them together:
- Coffee: 240 mL
- Milk: 60 mL
- Apple juice: 120 mL
- Broth: 8 oz = 240 mL (1 oz = 30 mL)
- Water: 10 oz = 300 mL (1 oz = 30 mL)
Now, add them together:
240 mL (coffee) + 60 mL (milk) + 120 mL (apple juice) + 240 mL (broth) + 300 mL (water) = 960 mL.
Thus, the total intake is 960 mL, which corresponds to D.
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