A nurse is caring for a patient who experiences severe cluster headaches.
At what point in the course of a new headache should the patient be instructed to take medications?

Twenty to thirty minutes after the onset of symptoms.

As soon as the patient senses the onset of the symptoms.

As soon as the patient’s pain becomes unbearable.

When the patient senses their symptoms are peaking.

Answer and Explanation

The Correct Answer is B

Choice B rationale
Patients who experience severe cluster headaches should be instructed to take medications as soon as they sense the onset of symptoms. Cluster headaches are characterized by severe, debilitating pain that reaches peak intensity within a short period of time, often within 15 minutes. Therefore, early intervention is crucial to manage the pain effectively.
Choice A rationale

Waiting twenty to thirty minutes after the onset of symptoms to take medications may not be effective for cluster headaches. The pain of a cluster headache often reaches peak intensity within 15 minutes, so delaying medication could result in unnecessary suffering.
Choice C rationale
Waiting until the patient’s pain becomes unbearable is not recommended for managing cluster headaches. The goal of treatment is to prevent or reduce pain, not to wait until it becomes unbearable.
Choice D rationale
Taking medications when the patient senses their symptoms are peaking is not the most effective strategy for managing cluster headaches. Given the rapid onset and severe pain associated with cluster headaches, medications should be taken as soon as the patient senses the onset of symptoms.

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Correct Answer is B

Explanation

Choice A rationale
This statement is not accurate. Relapsing-remitting multiple sclerosis (RRMS) is characterized by periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These episodes are followed by periods of remission, where the disease does not progress. Therefore, RRMS does not cause a steady and gradual decline in function.
Choice B rationale
This is the correct answer. Stress and extreme fatigue can trigger a relapse in RRMS1. Therefore, it is important for patients to avoid these triggers to manage their symptoms effectively.
Choice C rationale
This statement is incorrect. RRMS is the most common disease course at the time of diagnosis. It is not the least common type of multiple sclerosis.
Choice D rationale
This statement is not accurate. Medications for RRMS, known as disease-modifying treatments (DMT), are designed to reduce the frequency and severity of relapses. They are not intended to be taken only during times of relapse, but rather on an ongoing basis to manage the disease.

A. By using the Romberg test B. By assessing the patient’s sensitivity to temperature and touch C. By observing the patient’s response to painful stimuli D. By observing the reaction of pupils to light

Correct Answer is C

Explanation

Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale

Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.

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A nurse is caring for a patient who experiences severe cluster headaches. At what point in the course of a new headache should the patient be instructed to take medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). What instruction should the nurse provide?

Correct Answer is B

Explanation

When providing care for a comatose patient, how should a nurse evaluate motor responses?

Correct Answer is C

Explanation

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A nurse is caring for a patient who experiences severe cluster headaches.
At what point in the course of a new headache should the patient be instructed to take medications?