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 D
Explanation
A. Emotional lability (rapid mood swings) can occur with brain injuries, but it is more commonly associated with damage to the frontal lobe, not the brainstem.
B. Personality changes are also more likely to result from damage to the frontal lobe or other areas of the brain responsible for behavior and personality, not the brainstem.
C. Diabetes insipidus can result from brain injury, particularly damage to the hypothalamus or pituitary gland, but it is not a direct consequence of brainstem injury.
D. Unstable vital signs are a common result of damage to the brainstem, which is responsible for regulating autonomic functions such as heart rate, blood pressure, and respiration. Damage to the brainstem can lead to life-threatening instability in these vital functions.
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.
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