A nurse is caring for a client who has chronic migraine headaches. The client asks the nurse if it could be a cerebral aneurysm. Which of the follow responses should the nurse use?
"If you have a cerebral aneurysm, you would be having seizures."
"If you have a cerebral aneurysm, you will experience nausea and vomiting."
"If you had a cerebral aneurysm, you would have a stiff neck."
"If you have a cerebral aneurysm, you typically will have no symptoms."
The Correct Answer is D
"If you have a cerebral aneurysm, you would be having seizures. “is incorrect because not all cerebral aneurysms cause seizures. Seizures may occur if the aneurysm ruptures and causes bleeding into the brain, but they are not a universal symptom of an unruptured cerebral aneurysm.
Choice B Reason:
"If you have a cerebral aneurysm, you will experience nausea and vomiting. “is incorrect because while headaches, nausea, and vomiting can occur with a ruptured cerebral aneurysm (subarachnoid hemorrhage), they are not necessarily present in all cases, especially with unruptured aneurysms.
Choice C Reason:
"If you had a cerebral aneurysm, you would have a stiff neck." is incorrect because a stiff neck (meningeal irritation) is typically associated with subarachnoid hemorrhage from a ruptured cerebral aneurysm, but it is not always present and is not a definitive symptom of an unruptured aneurysm.
Choice D Reason:
"If you have a cerebral aneurysm, you typically will have no symptoms." Cerebral aneurysms can vary greatly in terms of their presentation and symptoms. While some aneurysms may cause symptoms such as headaches, nausea, vomiting, seizures, or a stiff neck, many cerebral aneurysms are asymptomatic and go unnoticed until they rupture or are incidentally discovered during imaging studies for other reasons.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"The nerves just go to sleep when I lie down because no message gets from my brain to the spinal cord." is incorrect because it does not accurately describe the mechanism of peripheral neuropathy. Peripheral neuropathy in diabetes is not simply the nerves "going to sleep" due to lack of communication between the brain and spinal cord.
Choice B Reason:
"The nerve damage may occur for unknown reasons in any individual" is incorrect because while the exact cause of peripheral neuropathy may not always be known, in the context of diabetes mellitus, the link between elevated blood sugar levels and nerve damage is well-established.
Choice C Reason:
"The older I get, there is less blood flowing to my feet. “is incorrect because while decreased blood flow (ischemia) can contribute to peripheral neuropathy in some cases, the primary mechanism in diabetic neuropathy is nerve damage due to hyperglycemia rather than reduced blood flow.
Choice D Reason:
"The elevated blood sugar from my diabetes can cause underlying nerve damage." Peripheral neuropathy is a common complication of diabetes mellitus, particularly when the condition is uncontrolled. Elevated blood sugar levels over time can lead to damage to the nerves, especially those in the feet and legs. This damage can result in symptoms such as numbness, tingling, burning sensations, or pain in the affected areas.
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason:
"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.
Choice B Reason:
"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.
Choice C Reason:
"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.
Choice D Reason:
"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.
Choice E Reason:
"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.
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