A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment?
(Select All that Apply.)
"Are you having any feelings of depression?"
"Are you experiencing any sensitivity to light?"
"Are you feeling any increase in your sexual drive?"
"Are you experiencing any episodes of 'panic-type' feelings?"
"Are you experiencing more fatigue as compared to before you had migraines?"
Correct Answer : A,D,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
MS hug is appropriate. The "MS hug" is a colloquial term used to describe a sensation of tightness, pressure, or squeezing around the torso or chest area experienced by some individuals with multiple sclerosis (MS). It is caused by spasms or contractions of the intercostal muscles (muscles between the ribs) or the diaphragm due to lesions in the spinal cord disrupting nerve signals. This sensation can be uncomfortable or painful for the individual.
Choice B Reason:
Lhermitte's sign is inappropriate. Lhermitte's sign is a common symptom experienced by individuals with MS but it presents differently. It is characterized by an electric shock-like sensation that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is caused by damage to the spinal cord's myelin sheath, leading to abnormal nerve signal transmission.
Choice C Reason:
Paroxysmal spasms is inappropriate. Paroxysmal spasms are sudden, involuntary muscle contractions or jerking movements that can occur in various parts of the body. While spasms are common in MS, they are not specifically associated with the sensation of tightness around the torso as described in the scenario.
Choice D Reason:
Trigeminal neuralgia is inappropriate. Trigeminal neuralgia is a condition characterized by sudden, severe facial pain often described as stabbing or electric shock-like. It is caused by irritation or damage to the trigeminal nerve, which is responsible for facial sensation. While individuals with MS may experience trigeminal neuralgia, it typically does not present with a tightening feeling around the torso.
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
"Have you had any nausea and vomiting with your headache?": This question is appropriate. Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm the diagnosis of a migraine headache.
Choice B Reason:
"Are you bothered by the lights in here?" This question is appropriate. Sensitivity to light, known as photophobia, is a classic symptom of migraines. Inquiring about light sensitivity can provide additional evidence for the diagnosis.
Choice C Reason:
"Have you noticed any confused or cloudy thinking?". This question is inappropriate. Confusion or cognitive symptoms are not typical of migraines. However, some individuals may experience difficulty concentrating or cognitive symptoms during a migraine aura. This question may help assess for aura symptoms.
Choice D Reason
Have you experienced or are you experiencing any strange smells?" This question is appropriate. Some individuals may experience olfactory hallucinations or sensitivity to odors during a migraine aura. Asking about strange smells can help identify possible aura symptoms.
Choice E Reason:
"Did you feel weak before the headache started or do you feel weak now?" This question is inappropriate. While weakness is not a typical symptom of migraines, some individuals may experience fatigue or muscle weakness during a migraine attack. This question may help assess the overall impact of the headache on the client.
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