A client with a history of migraines comes to a clinic with a throbbing headache. What Questions should the nurse include in the assessment?
“Have you experienced any nausea or vomiting with your headache?”
“Are the lights in here bothering you?”
“Have you noticed any confusion or clouded thinking?”
“Have you smelled anything unusual or are you currently smelling anything strange?”
“Did you feel weak before the headache started or are you feeling weak now?”
The Correct Answer is A
Choice A rationale
Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm a diagnosis of a migraine.
Choice B rationale
Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the question “Are the lights in here bothering you?” is less specific to migraines as it could be indicative of several other conditions as well.
Choice C rationale
While confusion or clouded thinking can occur with migraines, it is not as common as other symptoms such as nausea, vomiting, and sensitivity to light.
Choice D rationale
Unusual smells, known as olfactory hallucinations, are not typically associated with migraines. They are more commonly associated with conditions such as epilepsy.
Choice E rationale
Weakness before the headache started or currently feeling weak now is not a typical symptom of migraines. It could be indicative of a more serious condition, such as a stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hyperoxia, or high oxygen levels, can cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated. Too much oxygen can lead to oxygen toxicity and cause damage to the lungs and other organs, including the brain.
Choice B rationale
A platelet count of 250,000/mm^3 is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice C rationale
A hemoglobin level of 16 g/dL is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice D rationale
A Glasgow Coma Scale score of 16 is not possible as the maximum score is 15. A higher score indicates a less severe injury, so it would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Correct Answer is A
Explanation
Choice A rationale
Vasogenic cerebral edema is the most common type of cerebral edema associated with stroke. It involves swelling outside of brain cells, and leaky blood vessels cause it.
Choice B rationale
Osmotic cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like diabetes-related ketoacidosis and hyponatremia.
Choice C rationale
Cellular, or cytotoxic, cerebral edema can occur due to traumatic brain injury and stroke. However, it is not the most common type of cerebral edema associated with stroke.
Choice D rationale
Interstitial cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like hydrocephalus and meningitis.
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