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 C
Explanation
A. A cervical collar is not necessary for a lumbar laminectomy. A cervical collar is used for neck surgeries or spinal cord injuries involving the cervical spine, not for lumbar procedures.
B. The head of the bed elevated 30 degrees may be appropriate for certain conditions, but after a lumbar laminectomy, it is typically recommended to keep the head of the bed flat or slightly elevated to reduce pressure on the spine.
C. Logrolling the client every 2 hr is the correct action. After a lumbar laminectomy, the nurse should use the logroll technique to turn the patient to prevent strain on the spine and promote proper healing.
D. Supine with her arms elevated on pillows is not the best position. While elevation of the arms may be helpful for comfort, the focus should be on protecting the lumbar spine and ensuring proper positioning to prevent strain.
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