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 D

Explanation

Choice A Reason:

Myelogram is not appropriate. This imaging test involves injecting contrast dye into the spinal canal to visualize the spinal cord and nerve roots. While it may help identify certain spinal cord abnormalities, it is not typically used as a primary diagnostic tool for multiple sclerosis.

Choice B Reason:

Brain natriuretic peptide (BNP) is not appropriate. This blood test measures the level of BNP, a hormone produced by the heart, which can be elevated in conditions such as heart failure. It is not used in the diagnosis of multiple sclerosis.

Choice C Reason:

Troponin level is not appropriate. Troponin is a protein released into the bloodstream during a heart attack or other heart-related conditions. This test is used to diagnose heart muscle damage and is not relevant to the diagnosis of multiple sclerosis.

Choice D Reason:

Lumbar puncture is appropriate. Also known as a spinal tap, a lumbar puncture involves collecting cerebrospinal fluid (CSF) from the spinal canal for analysis. In the diagnosis of multiple sclerosis, analysis of CSF can help identify certain abnormalities, such as an elevated level of immunoglobulin G (IgG) or the presence of oligoclonal bands, which are often indicative of inflammation in the central nervous system. Therefore, a lumbar puncture is commonly ordered to assist with the diagnosis of multiple sclerosis.

A. Decreased pulmonary vascular resistance B. Hypercapnia C. Hypoventilation D. Respiratory alkalosis

Correct Answer is D

Explanation

Correct answer: D

Choice A Reason:

Decreased pulmonary vascular resistance is incorrect. Inflammatory mediators released in response to a pulmonary embolism can lead to vasoconstriction and increased pulmonary vascular resistance. This is part of the body's response to redirect blood flow away from the affected area of the lung and maintain adequate perfusion to other areas.

Choice B Reason:

Hypercapnia is incorrect. Hypercapnia refers to elevated levels of carbon dioxide (CO2) in the blood.Hypocapnia usually is present with embolism; hypercapnia, on the other hand, is rare.

Choice C Reason:

Hypoventilation is incorrect. Hypoventilation occurs when there is inadequate ventilation of the lungs relative to metabolic demands. In the context of a pulmonary embolism, hypoventilation can occur due to factors such as pain, respiratory muscle fatigue, or impaired gas exchange, all of which can be influenced by the release of inflammatory mediators.

Choice D Reason:

Respiratory alkalosis is correct.In response to the blockage and the resulting inflammation, the body often increases the respiratory rate as a compensatory mechanism to maintain adequate oxygen levels and remove carbon dioxide.Due to the increased breathing rate, there is excessive exhalation of carbon dioxide, leading to a decrease in the partial pressure of CO2 in the blood. This results in an increase in blood pH, causing respiratory alkalosis.

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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 a client who is being evaluated for multiple sclerosis. Which of the following tests should the nurse anticipate the provider will order to assist with diagnosis?

Correct Answer is D

Explanation

A nurse is caring for a client who has a pulmonary embolism. The nurse should identify that the release of inflammatory mediators leads to which of the following pathologic findings?

Correct Answer is D

Explanation

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Which of the following information should the nurse include when educating a client who has pulmonary edema as a result of a pre-existing cardiac condition? (Select All that Apply.)

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.)

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia? (Select All that Apply.)

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.)

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.)