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","B","D"]
Explanation
Choice A Reason:
Genetics is correct. There is evidence to suggest that genetics play a role in the development of multiple sclerosis. Although no single gene has been identified as the cause of MS, certain genetic variations have been associated with an increased risk of developing the disease. Having a first-degree relative with MS increases an individual's risk, although the overall genetic contribution to MS susceptibility is thought to be relatively modest.
Choice B Reason:
Environmental factors is correct. Environmental factors are believed to play a significant role in the development of multiple sclerosis, particularly in individuals with a genetic predisposition. Factors such as vitamin D deficiency, smoking, exposure to certain infections (such as Epstein-Barr virus), and geographic location (latitude) have been implicated as potential triggers for MS development.
Choice C Reason:
Upper respiratory infections is incorrect. While infections may trigger exacerbations or relapses in individuals with existing multiple sclerosis, there is limited evidence to suggest that upper respiratory infections contribute directly to the development of MS. However, some research suggests that viral infections, particularly those occurring during childhood or adolescence, may influence the risk of developing MS later in life.
Choice D Reason:
Autoimmune factors is correct. Multiple sclerosis is widely recognized as an autoimmune disease, characterized by immune-mediated inflammation and damage to the central nervous system. In MS, the immune system mistakenly attacks myelin, the protective covering of nerve fibers, leading to demyelination and neurological dysfunction. Autoimmune factors are therefore considered central to the pathogenesis of MS.
Choice E Reason:
Urinary tract infections is incorrect. While urinary tract infections (UTIs) are common in individuals with multiple sclerosis due to bladder dysfunction associated with the disease, there is no direct evidence to suggest that UTIs contribute to the development of MS.
Correct Answer is A
Explanation
Choice A Reason:
The client should maintain systolic BP between 120 and 129 mm Hg. This option aligns with current guidelines for blood pressure management following a transient ischemic attack (TIA). Tight blood pressure control is recommended to reduce the risk of recurrent cerebrovascular events, such as stroke. Maintaining systolic blood pressure (SBP) between 120 and 129 mm Hg has been associated with significant risk reduction in stroke recurrence compared to higher blood pressure targets. Therefore, this option reflects the recommended approach for blood pressure management in individuals with a history of TIA.
Choice B Reason:
The client should maintain systolic BP between 136 and 140 mm Hg: This option suggests a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 136 to 140 mm Hg may pose an increased risk of recurrent cerebrovascular events compared to tighter blood pressure control.
Choice C Reason:
The client should maintain systolic BP between 141 and 145 mm Hg. Similarly, this option proposes a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 141 to 145 mm Hg may not provide adequate protection against stroke recurrence compared to tighter blood pressure control.
Choice D Reason:
The client should maintain systolic BP between 130 and 135 mm Hg. While this option suggests a systolic blood pressure (SBP) range that is closer to the recommended target compared to options B and C, it still falls slightly above the optimal range for blood pressure management following a TIA. Tighter blood pressure control, ideally below 130 mm Hg, is typically preferred to reduce the risk of recurrent cerebrovascular events.
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