A nurse is caring for a patient with a recent history of migraines.
What aspect of this patient’s current status may contraindicate the safe use of triptans?

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.

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.