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 D
Explanation
Choice A rationale
Respiratory therapy is primarily concerned with the treatment and management of a patient’s breathing. While swallowing difficulties can potentially lead to respiratory issues such as aspiration pneumonia, the primary role of evaluating and treating swallowing difficulties falls outside the scope of respiratory therapy.
Choice B rationale
Nutritional therapy would be involved in managing the dietary needs of a patient with Parkinson’s disease, including modifications to food texture and liquid consistency if swallowing difficulties are present. However, the evaluation and treatment of the swallowing difficulty itself would be managed by a speech therapist.
Choice C rationale
Occupational therapy could assist with adaptations to enhance the patient’s feeding skills and independence during meals. However, the specific evaluation and treatment of swallowing function is typically within the scope of a speech therapist.
Choice D rationale
Speech therapists, or speech-language pathologists, are the professionals specifically trained to evaluate and treat individuals with speech, language, voice, and swallowing disorders. This would include a patient with Parkinson’s disease experiencing difficulty swallowing.
Correct Answer is D
Explanation
Choice A rationale
Monitoring volume status is important in managing increased ICP, but it is not a direct intervention to reduce ICP78.
Choice B rationale
Ensuring proper ventriculostomy transducer levels is important in monitoring ICP, but it is not a direct intervention to reduce ICP78.
Choice C rationale
Managing sedation can help control agitation and excessive muscular activity, which can potentially increase ICP. However, it is not a direct intervention to reduce ICP78.
Choice D rationale
Elevating the head of the bed 15 degrees can help promote venous drainage, enhance cerebral perfusion, and reduce ICP78.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.