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?"

Answer and Explanation

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.

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

Explanation

Choice A Reason:

Decreased visual acuity is correct. Yes, decreased visual acuity, including issues such as poor depth perception, reduced peripheral vision, and difficulty with contrast sensitivity, can contribute to falls and head injuries in older adults.

Choice B Reason:

Motor vehicle crashes is incorrect. While motor vehicle crashes can cause head injuries in individuals of all ages, they are less common among older adults compared to younger age groups.

Choice C Reason:

Polypharmacy is correct. Yes, polypharmacy, which refers to the use of multiple medications concurrently, is a common risk factor for falls and head injuries in older adults. Certain medications, especially those with sedative or psychotropic effects, can increase the risk of falls and accidents.

Choice D Reason:

Weakness is correct. Yes, weakness, frailty, and decreased muscle strength are common age-related changes that can increase the risk of falls and subsequent head injuries in older adults.

Choice E Reason:

Chronic hypertension, particularly when poorly controlled, can contribute to an increased risk of falls in older adults through various mechanisms:Hypertension medications or the condition itself can lead to orthostatic hypotension. This can cause dizziness or lightheadedness, increasing the risk of falls.Chronic hypertension is a major risk factor for cerebrovascular disease, including strokes. These events can lead to neurological deficits such as weakness, numbness, or impaired balance, predisposing individuals to falls.

Choice F Reason:

Previous military experience is incorrect. While previous military experience may contribute to certain health conditions or injuries in older adults, it is not a common reason for head injuries specifically related to falls or accidents in this population.

A. Temperature 36.3° C (97.4° F) B. Respirations 12/min C. Blood pressure 184/88 mm Hg D. Heart rate 54/min E. Calcium level 7.0 mg/dL

Correct Answer is ["A","D"]

Explanation

Choice A Reason:

Temperature 36.3°C (97.4°F) is correct. Hypothermia is a characteristic finding in neurogenic shock due to the loss of sympathetic control over temperature regulation and peripheral vasodilation. This can lead to heat loss from the skin surface and a decrease in core body temperature.

Choice B Reason:

Respirations 12/min is incorrect. Respiratory rate is usually not significantly affected in neurogenic shock. However, individuals with high cervical or upper thoracic spinal cord injuries may experience respiratory compromise due to paralysis of respiratory muscles, but this is not a typical feature of neurogenic shock.

Choice C Reason:

Incorrect: Neurogenic shock typically results inhypotension(low blood pressure) due to vasodilation. The given blood pressure reading is elevated, which is not consistent with neurogenic shock.

Choice D Reason:

Heart rate 54/min is correct. Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity resulting from the loss of sympathetic tone. The heart rate may be slow and may decrease further over time.

Choice E Reason:

Calcium level 7.0 mg/dL is incorrect, Calcium levels are not directly related to neurogenic shock. Neurogenic shock primarily involves the loss of sympathetic tone and the resulting hemodynamic changes, rather than alterations in calcium metabolism.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client in the emergency department who sustained a head injury due to a fall. Which of the following are common reasons for head injuries in older adults? (Select All that Apply.)

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

Explanation

A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.) (Select All that Apply.)

Correct Answer is ["A","D"]

Explanation

Which of the following risk factors is associated with a client having a higher risk of experiencing status asthmaticus?

A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

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A nurse is planning care for a client who has multiple sclerosis and is receiving methylprednisolone. Which of the following adverse effects should the nurse anticipate? (Select all that apply.)

A nurse is caring for a client who has chronic migraine headaches. The client asks the nurse if it could be a cerebral aneurysm. Which of the follow responses should the nurse use?

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.)