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 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.

A. Assessing muscle strength B. Checking for facial symmetry C. Checking peripheral pulses D. Evaluating vision changes E. Checking for aphasia F. Asking about smoking history

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale
Assessing muscle strength is important after a fall as it can help determine if the fall was due to muscle weakness or other neurological issues.
Choice B rationale
Checking for facial symmetry is crucial as asymmetry may indicate a stroke or other serious neurological condition.
Choice C rationale
While checking peripheral pulses is important in general, it may not be the top priority in this case unless there is a specific reason to suspect circulatory issues.
Choice D rationale
Evaluating vision changes is important as sudden vision loss or changes could indicate a serious condition such as a stroke.
Choice E rationale
Checking for aphasia, or difficulty with language, is crucial as it can be a sign of a stroke or other serious neurological condition.
Choice F rationale
Asking about smoking history may not be a priority in the immediate assessment of a patient who has just fallen.

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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 caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the following can cause unfavorable outcomes for this client?

Correct Answer is A

Explanation

A nurse in the emergency department is evaluating a client who was brought in by a neighbor after suddenly falling while walking. What assessments should the nurse prioritize?

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client who has chronic migraine headaches. The client asks if they had a cerebral aneurysm, which of the following responses should the nurse use?

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