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 A
Explanation
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
Correct Answer is ["3"]
Explanation
Step 1 is: Identify the prescribed dose, which is 0.3 mg.
Step 2 is: Identify the available amount, which is 0.1 mg per tablet.
Step 3 is: Divide the prescribed dose by the available amount to find the number of tablets. So,
0.3 mg ÷ 0.1 mg/tablet equals 3 tablets. Therefore, the nurse should administer 3 tablets per dose.
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