A client comes in with complaints of a headache. The client states, "I always wake up with a headache in the morning, but it gets better in a couple hours. I notice that it always gets worse if I cough or sneeze." What action by the nurse is most appropriate?

Administer morphine 10 mg IV every 4 hours for the pain.

Palpate the occipital lymph nodes.

Assess the client's neurological status.

Explain that migraine headaches can last a long time.

Answer and Explanation

The Correct Answer is C

Choice A reason: Morphine treats severe pain but isn’t first-line for headaches worsened by coughing, which may signal increased intracranial pressure. Without neurological assessment, this risks masking symptoms of serious conditions like brain tumors, delaying critical diagnosis and intervention.

Choice B reason: Palpating occipital lymph nodes checks for infection or inflammation, but headaches worsened by coughing or sneezing suggest intracranial issues, not lymphatic ones. This action misses the priority of assessing brain function tied to the client’s specific symptom pattern.

Choice C reason: Neurological assessment, like checking reflexes or pupil response, is vital for morning headaches worsening with coughing, hinting at possible intracranial pressure from masses or bleeds. It’s the most direct step to rule out life-threatening causes promptly.

Choice D reason: Explaining migraines assumes a diagnosis without evidence. Morning headaches improving later, worsened by strain, don’t align with typical migraine patterns, risking misdiagnosis of serious conditions like sinus thrombosis, necessitating neurological evaluation over premature reassurance.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Small/moderate brown cerumen is normal, not a sign of infection, which shows pus or redness. Assessing further wastes effort, as cerumen protects the canal, and no symptoms like pain or hearing loss suggest pathology here requiring investigation.

Choice B reason: Documenting small/moderate brown cerumen as normal is correct, as it’s a protective earwax variant. Absent symptoms, this finding needs no intervention, aligning with standard practice to record typical ear assessments without escalating care unnecessarily in this case.

Choice C reason: Teaching hygiene isn’t needed for normal cerumen levels, which self-regulate. Excessive cleaning risks impaction or injury, and with no blockage or symptoms, this action overcomplicates a routine finding better left to natural ear processes here.

Choice D reason: Noting for ear drops assumes intervention for a non-issue. Normal brown cerumen doesn’t require softening or removal unless symptomatic, making this step premature and unnecessary, diverging from evidence-based care for typical ear findings fully.

A. The client has a family history of cognitive disorders. B. The client has recently begun a new medication. C. The client's cognition has declined over a period of several months to a year. D. The client has a history of hypertension.

Correct Answer is B

Explanation

Choice A reason: Family history suggests dementia, not delirium. Dementia progresses slowly, unlike delirium’s acute onset, making this less indicative of the sudden cognitive shift typical of delirium, especially without a rapid trigger in this case fully here.
Choice B reason: New medication often causes delirium in older adults via anticholinergic effects or toxicity. This acute, reversible change aligns with delirium’s hallmark sudden onset, making it the most suggestive finding for this cognitive impairment accurately here.
Choice C reason: Decline over months to a year fits dementia, not delirium. Delirium is acute, not chronic, excluding this gradual progression as a sign of the rapid cognitive shift delirium presents in this assessment entirely and fully.
Choice D reason: Hypertension risks vascular dementia, not delirium. It’s a chronic factor, not an acute trigger, missing delirium’s sudden, reversible nature tied to immediate causes like drugs, rendering it less relevant here comprehensively and clearly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client comes in with complaints of a headache. The client states, "I always wake up with a headache in the morning, but it gets better in a couple hours. I notice that it always gets worse if I cough or sneeze." What action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

Correct Answer is B

Explanation

An older adult client has been admitted due to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive impairment?

Correct Answer is B

Explanation

The client reports a decreased sense of smell for the past week. Which condition would the nurse assess for?

The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?

The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?