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?”

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Maintaining systolic BP between 141 and 145 mm Hg is considered high and can increase the risk of stroke.
Choice B rationale

The client should maintain systolic BP between 120 and 129 mm Hg. This is considered a normal blood pressure range and can help reduce the risk of stroke.
Choice C rationale
Maintaining systolic BP between 130 and 135 mm Hg is considered elevated and can increase the risk of stroke.
Choice D rationale
Maintaining systolic BP between 136 and 140 mm Hg is considered high and can increase the risk of stroke.

A. A nurse provides nonpharmacological pain interventions to each client equally. B. A nurse fulfills a promise to a client that they will return with their pain medication. C. A nurse administers a scheduled pain medication for a client who is having pain. D. A nurse gives a client the choice of when to take a pain medication.

Correct Answer is D

Explanation

Choice A rationale
Providing nonpharmacological pain interventions to each client equally is an example of justice, not autonomy. Justice in healthcare refers to treating all patients fairly and equitably.
Choice B rationale
Fulfilling a promise to a client that they will return with their pain medication is an example of fidelity, not autonomy. Fidelity refers to being faithful to commitments and promises.
Choice C rationale
Administering a scheduled pain medication for a client who is having pain is an example of beneficence, not autonomy. Beneficence refers to taking actions that are of benefit to the patient.
Choice D rationale
Giving a client the choice of when to take a pain medication is an example of autonomy. Autonomy in healthcare refers to the patient’s right to make decisions about their own care.

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A client with a history of migraines comes to a clinic with a throbbing headache. What Questions should the nurse include in the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of autonomy?

Correct Answer is D

Explanation

A client with a history of migraines comes to a clinic with a throbbing headache. What Questions should the nurse include in the assessment?

A nurse is caring for a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will maintain cerebral perfusion pressure constant?

A nurse is providing care to a client who has Parkinson’s disease and is having difficulty swallowing. Which of the following departments should the nurse plan to contact for a consultation?

A nurse is reinforcing teaching to a group of nursing students about possible psychosocial changes a client might have after sustaining a neurological injury. Which of the following should the nurse mention?

A nurse is admitting a patient with a subarachnoid hemorrhage and expects to administer which of the following medications to decrease intracranial pressure (ICP)?

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a possible consequence of a TBI?

A nurse is caring for a client who has headaches. Which of the following precipitating factors is common in both tension-type headaches and cluster headaches?

A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad. The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?