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?”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.
Choice B rationale
Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.
Choice C rationale
Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.
Choice D rationale
Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.
Correct Answer is A
Explanation
Choice A rationale
The hospital pharmacist is the most appropriate resource for a nurse to consult for information on medication compatibility. Pharmacists have specialized knowledge and access to resources that provide information on drug interactions, including those between ampicillin and gentamicin sulfate. They can provide accurate and up-to-date information on whether these two medications can be safely administered together.
Choice B rationale
While the health care provider prescribes the medication, they may not have the most current or detailed information on drug compatibility. It is the pharmacist’s role to have this specialized knowledge.
Choice C rationale
Medication sales representatives are primarily focused on promoting their company’s products. They may not have comprehensive knowledge of drug interactions, especially between drugs from different companies.
Choice D rationale
The nurse manager oversees the nursing staff and coordinates care, but they may not have specific knowledge about all drug interactions. The hospital pharmacist is the most appropriate resource for this information.
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