A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Administering hydromorphone as needed

Distracting the patient with activity

Dimming the lights and reducing stimulation

Initiating a patient-controlled analgesia (PCA) of morphine sulfate .

Answer and Explanation

The Correct Answer is C

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.

Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.

A. The patient has angina B. The patient has a history of asthma C. The patient is 75 years old D. The patient’s migraines are associated with psychosocial stress

Correct Answer is A

Explanation

Choice A rationale
Triptans, a class of medications commonly used to treat migraines, can cause vasoconstriction, or narrowing of the blood vessels. This can be problematic for patients with angina, a condition characterized by reduced blood flow to the heart. Vasoconstriction could potentially exacerbate this condition, leading to an increased risk of a heart attack. Therefore, the use of triptans may be contraindicated in patients with angina.

Choice B rationale
While asthma is a serious condition that requires careful management, it is not typically considered a contraindication for the use of triptans. Triptans work primarily on the blood vessels in the brain and do not typically interact with the bronchial tubes affected by asthma.
Choice C rationale
Age alone is not typically a contraindication for the use of triptans. However, older adults may have a higher risk of certain health conditions, such as heart disease, which could make the use of triptans more risky. It’s important for healthcare providers to consider the overall health status of the patient, not just their age, when deciding whether to prescribe triptans.
Choice D rationale
While stress can certainly exacerbate migraines, it is not typically a contraindication for the use of triptans. Triptans are designed to relieve the pain and other symptoms of migraines, regardless of their cause. If a patient’s migraines are triggered by stress, it may be beneficial to explore stress management techniques in addition to medication.

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A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

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