A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following questions should the nurse include in the assessment?
(Select All that Apply.)
"Have you had any nausea and vomiting with your headache?"
"Are you bothered by the lights in here?"
"Have you noticed any confused or cloudy thinking?"
"Have you experienced or are you experiencing any strange smells?"
"Did you feel weak before the headache started or do you feel weak now?"
Correct Answer : A,B,D
Choice A Reason:
"Have you had any nausea and vomiting with your headache?": This question is appropriate. Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm the diagnosis of a migraine headache.
Choice B Reason:
"Are you bothered by the lights in here?" This question is appropriate. Sensitivity to light, known as photophobia, is a classic symptom of migraines. Inquiring about light sensitivity can provide additional evidence for the diagnosis.
Choice C Reason:
"Have you noticed any confused or cloudy thinking?". This question is inappropriate. Confusion or cognitive symptoms are not typical of migraines. However, some individuals may experience difficulty concentrating or cognitive symptoms during a migraine aura. This question may help assess for aura symptoms.
Choice D Reason
Have you experienced or are you experiencing any strange smells?" This question is appropriate. Some individuals may experience olfactory hallucinations or sensitivity to odors during a migraine aura. Asking about strange smells can help identify possible aura symptoms.
Choice E Reason:
"Did you feel weak before the headache started or do you feel weak now?" This question is inappropriate. While weakness is not a typical symptom of migraines, some individuals may experience fatigue or muscle weakness during a migraine attack. This question may help assess the overall impact of the headache on the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason:
"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.
Choice B Reason:
"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.
Choice C Reason:
"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.
Choice D Reason:
"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.
Choice E Reason:
"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A Reason:
Paresthesia is appropriate. Paresthesia, or abnormal sensations such as tingling, numbness, or burning, is a common neurological symptom in individuals with multiple sclerosis. It results from damage to the nerves or disruption of nerve signals in the central nervous system.
Choice B Reason:
Nausea and vomiting is inappropriate. While nausea and vomiting can occur in individuals with multiple sclerosis, they are not considered hallmark symptoms of the disease. These symptoms may be associated with other factors such as medications, autonomic dysfunction, or complications such as urinary tract infections.
Choice C Reason:
Dysphagia is appropriate. Dysphagia, or difficulty swallowing, is a common symptom in individuals with multiple sclerosis, particularly as the disease progresses. It can result from damage to the nerves that control swallowing muscles or from impaired coordination of swallowing reflexes.
Choice D Reason:
Spasticity is appropriate. Spasticity, or muscle stiffness and involuntary muscle contractions, is a common symptom in individuals with multiple sclerosis. It occurs due to damage to the nerve fibers that control muscle movement and can lead to difficulty with movement, walking, and muscle control.
Choice E Reason:
Vertigo is appropriate. Vertigo, or the sensation of spinning or dizziness, can occur in individuals with multiple sclerosis, particularly if lesions develop in areas of the brain involved in balance and coordination.
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