The nurse is providing care to a patient with a migraine headache. What action should the nurse take?

Provide a dark quiet environment

Eliminate all caffeine from the patient's diet

Monitor for cognitive impairment

Medicate with opioids

Answer and Explanation

The Correct Answer is A

A. Providing a dark, quiet environment is an appropriate intervention for a client with a migraine headache. Migraines are often aggravated by bright lights and loud noises, so creating a calm, low-stimulation environment can help alleviate symptoms.

B. While caffeine can be a trigger for some individuals with migraines, it is not necessary to eliminate all caffeine. In fact, caffeine is sometimes included in medications for migraines to enhance their effectiveness.

C. Cognitive impairment is not a typical concern for migraines unless the headache is severe or prolonged. Monitoring for cognitive impairment would not be the primary action in this scenario.

D. Opioids are not recommended for the treatment of migraines due to their potential for abuse and side effects. NSAIDs, triptans, and other specific migraine treatments are preferred.

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Correct Answer is C

Explanation

A. A thrombotic stroke is typically caused by a blood clot that forms in an artery supplying blood to the brain, usually due to atherosclerosis. While it is a possible cause of stroke, it is not the most likely in this patient with atrial fibrillation.

B. A cerebral aneurysm involves a weakness in the blood vessel wall that can lead to rupture and bleeding, causing a hemorrhagic stroke, but this is not the most common type of stroke in patients with atrial fibrillation.

C. Embolic stroke occurs when a clot or other debris (such as a thrombus) breaks off from a distant part of the body (like the heart in atrial fibrillation) and travels to the brain, blocking a cerebral artery. This is the most common type of stroke in patients with atrial fibrillation due to the formation of clots in the left atrium that can embolize to the brain.

D. Hemorrhagic stroke is caused by the rupture of a blood vessel in the brain, leading to bleeding. It is not the most common type of stroke in patients with atrial fibrillation, though it can occur if there is coagulopathy or anticoagulant therapy.

A. Keep familiar personal items in client's room. B. Hang abstract pictures on the walls. C. Encourage bright lighting in the room. D. Keep the television on at all times.

Correct Answer is A

Explanation

A. Keep familiar personal items in the client's room is an effective strategy to help reduce confusion in clients with Alzheimer's disease. Familiar items can provide comfort and a sense of security, which can help orient the client and reduce agitation.

B. Hang abstract pictures on the walls is not recommended for clients with Alzheimer's disease, as abstract art may be confusing or difficult for them to interpret. Instead, simple and familiar images are more beneficial for orientation.

C. Encourage bright lighting in the room may cause discomfort or confusion for some individuals with Alzheimer's disease, especially if they are sensitive to light. Soft, ambient lighting is often more calming.

D. Keep the television on at all times may be overstimulating and contribute to confusion. It is better to create a calm and quiet environment to help the client focus and reduce agitation.

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The nurse is providing care to a patient with a migraine headache. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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