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 C

Explanation

Choice A rationale

Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.

Choice B rationale

While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.

Choice C rationale

Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.

Choice D rationale

Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.

A. Instill mineral oil into the canal and immediately irrigate to remove the impacted wax. B. Instill a small amount of mineral oil into the canal, then have the patient return in 30 minutes for wax removal. C. Irrigate the ear with cold water until all the wax is removed. D. Irrigate the ear with warm water and a high amount of otic pressure.

Correct Answer is B

Explanation

Choice A rationale
Instilling mineral oil into the canal and immediately irrigating to remove the impacted wax is not typically recommended. This approach may not allow enough time for the mineral oil to soften the cerumen, making it more difficult to remove and potentially causing discomfort or injury.
Choice B rationale
Instilling a small amount of mineral oil into the canal, then having the patient return in 30 minutes for wax removal is a common and effective method for managing cerumen impaction. The mineral oil helps to soften the cerumen, making it easier to remove through irrigation.
Choice C rationale
Irrigating the ear with cold water is not typically recommended. Cold water can cause discomfort and potentially lead to vertigo.
Choice D rationale
Irrigating the ear with warm water and a high amount of otic pressure is not typically recommended. High pressure can potentially damage the ear canal or tympanic membrane.

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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 nurse is caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?

Correct Answer is C

Explanation

A patient is being evaluated for hearing loss. The doctor is unable to examine the tympanic membrane due to a blockage caused by cerumen. What actions can the nurse take to allow for an examination?

Correct Answer is B

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?