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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Reducing the client's interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and worsen the client's agitation and delusions. It does not address the client's emotional distress.

Choice B rationale:

Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client's focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.

Choice C rationale:

Awakening the client earlier for daily morning care may further disrupt the client's sleep patterns and worsen agitation. It does not address the underlying issue of delusional thoughts and the client's emotional distress.

Choice D rationale:

Clarifying reality with the client about delusional thoughts can be counterproductive in dementia care. The client's cognitive impairment may make it challenging for them to understand or accept the clarification, leading to increased frustration and agitation. It is essential to use a more empathetic and therapeutic approach.

A. Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back. B. Insert a gloved finger into the rectum and gently massage the rectal sphincter. C. Stop the procedure and observe for a reduction in symptoms before continuing. D. Encourage the client to take slow, deep breaths while continuing the procedure. E. Encourage the client to take slow, deep breaths while continuing the procedure.

Correct Answer is A

Explanation

Choice A rationale:

Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.

Choice B rationale:

Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.

Choice C rationale:

Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.

Choice D rationale:

Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?​​​​​​

Correct Answer is B

Explanation

During a fecal impaction removal, an older client complains of feeling dizzy and cold. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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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?