A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following
Questions should the nurse include in the assessment?

“Have you experienced any nausea or vomiting with your headache?”

“Are the lights in this room bothering you?”

“Have you noticed any confusion or clouded thinking?”

“Did you feel weak before the headache started or do you feel weak now?”

Answer and Explanation

The Correct Answer is A

Choice A rationale

Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.

Choice B rationale

Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.

Choice C rationale

While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.

Choice D rationale

Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.

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Correct Answer is ["A","C","D","E"]

Explanation

Smoking, Diabetes, Atherosclerosis, and Weak pedal pulses.

Factors that contribute to poor circulation to the limb include:

Smoking: It can cause constriction and damage to the blood vessels, leading to poor circulation.
Diabetes: High blood sugar levels can damage blood vessels and nerves, leading to poor circulation.
Atherosclerosis: This is a condition where plaque builds up in the arteries, narrowing them and reducing blood flow.
Weak pedal pulses: This can be a sign of reduced blood flow to the lower extremities. A sodium-restricted diet (Choice B) is not typically associated with poor circulation.

A. The patient’s blood pressure is 80/56 mm Hg. B. The patient reports lower extremity weakness. C. The patient’s temperature is 38.2°C (100.8 F). D. The patient reports severe itching.

Correct Answer is A

Explanation

Choice A rationale

The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.

Choice B rationale

Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.

Choice C rationale

A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.

Choice D rationale

Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.

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A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the followingQuestions should the nurse include in the assessment?

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Correct Answer is ["A","C","D","E"]

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A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following
Questions should the nurse include in the assessment?