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","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.
Correct Answer is A
Explanation
Choice A Reason:
Smoking tobacco is the primary and most significant risk factor for emphysema. Tobacco smoke contains harmful chemicals and toxins that directly damage the lungs. Chronic exposure to cigarette smoke leads to inflammation and destruction of lung tissue, particularly the alveoli, contributing to the development of emphysema.
Choice B Reason:
Between 20 to 30 years of age. While smoking at any age is harmful to lung health, the risk of developing emphysema increases with prolonged exposure to tobacco smoke over many years. Emphysema is typically a disease of middle to older age, with symptoms often appearing after years of smoking.
Choice C Reason:
Asthma is a chronic inflammatory condition of the airways characterized by reversible airflow obstruction and airway hyperresponsiveness. While asthma and emphysema are both respiratory diseases, they have distinct pathophysiological mechanisms and risk factors. Asthma is not a direct cause of emphysema, although some individuals with poorly controlled asthma may develop chronic obstructive pulmonary disease (COPD), which includes emphysema as one of its components.
Choice D Reason:
Pollution is not correct. Environmental pollution, including air pollution from industrial emissions, vehicle exhaust, and particulate matter, can contribute to respiratory problems and exacerbate pre-existing lung conditions. While exposure to pollution can worsen respiratory symptoms and lung function, it is not the primary cause of emphysema. However, long-term exposure to certain pollutants may increase the risk of developing respiratory diseases, including COPD, which encompasses emphysema.

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