A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief.
Which intervention should the nurse offer?
Monitor your blood pressure.
Take a few days off work.
Learn muscle relaxation techniques.
Lie down in a dark, quiet room.
The Correct Answer is D
Choice A rationale:
Monitoring blood pressure is a general health assessment measure and may not directly contribute to pain relief in a client with migraine headaches. While it's essential to manage blood pressure as part of overall health, this choice does not address the client's specific request for pain relief.
Choice B rationale:
Taking a few days off work may provide some relief from external stressors, but it is not a reliable intervention for migraine pain relief. Migraine management typically involves strategies that directly target headache symptoms.
Choice C rationale:
Learning muscle relaxation techniques can be helpful in managing migraine headaches. Relaxation techniques, such as progressive muscle relaxation, can reduce muscle tension and help alleviate headache symptoms. However, it may not be the highest-priority intervention.
Choice D rationale:
Lying down in a dark, quiet room is the most appropriate intervention for obtaining pain relief from a migraine headache. This approach minimizes sensory stimuli, reduces external factors that may exacerbate the headache, and promotes relaxation. It is a well-established non-pharmaceutical method for managing migraine pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.
Correct Answer is C
Explanation
- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Therefore, option C is the correct answer, while options A, B, and D are incorrect.
Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.
Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.
Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in technique.
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