A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache?

Tension headache

Migraine headache

Cluster headache

Sinus headache

Answer and Explanation

The Correct Answer is B

A) Tension headache: Tension headaches are typically characterized by a dull, aching pain that feels like a tight band around the head. They are often associated with muscle tension and stress, and they generally do not involve nausea, vomiting, or sensitivity to light and sound, which are more indicative of migraines.
B) Migraine headache: The symptoms described—severe pain rated 10 out of 10, nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia)—are classic signs of a migraine headache. Migraines are often intense and can be accompanied by these additional symptoms, making this the most likely diagnosis.
C) Cluster headache: Cluster headaches are extremely painful and typically occur in cyclical patterns or clusters. They are often unilateral (one-sided) and can cause severe pain, redness of the eye, and nasal congestion. While they can be very painful, they are less commonly associated with nausea, vomiting, and sensitivity to light and sound as described in the scenario.
D) Sinus headache: Sinus headaches are associated with sinusitis and typically involve pain and pressure in the forehead, cheeks, or nose area, often accompanied by nasal congestion. They usually do not present with the intensity of pain, nausea, vomiting, and sensitivity to light and sound seen in migraines.

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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

A) Wear socks when walking around the home: Wearing socks, especially if they have smooth soles, can increase the risk of slipping on hard surfaces. Non-slip footwear is recommended for preventing falls. Therefore, recommending socks for walking may not address the safety concerns effectively.
B) Install grab bars in the bathtub: Installing grab bars in the bathtub is a crucial safety measure for preventing falls and providing support for older adults while bathing. This helps reduce the risk of slips and injuries in a common high-risk area for falls.
C) Secure rugs with adhesive tape: Securing rugs with adhesive tape helps prevent them from slipping, which can significantly reduce the risk of tripping and falling. Loose or unsecured rugs are common hazards in the home environment.
D) Use nightlights along stairways and walkways: Using nightlights along stairways and walkways improves visibility and helps prevent falls during the night. Adequate lighting is essential for older adults to navigate their homes safely.
E) Install handrails on both sides of all stairways: Installing handrails on both sides of stairways provides additional support and stability, which is particularly important for older adults to prevent falls while using stairs. This enhancement helps ensure safer navigation of stairs.

A. Egophony B. normal voice transmission. C. Air filled lungs D. Bronchophony

Correct Answer is A

Explanation

A. Egophony: Egophony is a type of abnormal voice sound transmission where the letter "E" is heard as an "A" when auscultated through a stethoscope. This can indicate underlying lung pathology, such as consolidation or infection, that alters the way sounds are transmitted through the lung tissue.
B. Normal voice transmission: Normal voice transmission would involve hearing the letter "E" clearly and accurately as the patient says it, without distortion. The presence of an "A" sound indicates an abnormal finding, not a normal one.
C. Air-filled lungs: Air-filled lungs typically transmit voice sounds clearly and normally. If the sound changes to an "A," this suggests a pathology that alters sound transmission, rather than indicating simply air-filled lungs.
D. Bronchophony: Bronchophony refers to the increased clarity of spoken sounds heard through the stethoscope over areas of lung consolidation, but it does not specifically describe the transformation of the letter "E" to "A." The specific change in sound transmission described here is characteristic of egophony.

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Naxlex Comprehensive Predictor Exams

Which of the following should the nurse include in her teaching plan to address home safety for an older adult client? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

During a respiratory physical assessment, the nurse directs the patient to say and repeat the letter E for the transmitted voice sounds assessment. The nurse by auscultation hears the letter A instead of E. This is known as:

Correct Answer is A

Explanation

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The test done to evaluate and compare the patency of the ulnar and radial arteries is:

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

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Which strategy can the nurse use to effectively approach the older adult client during the health history?