The nurse is working in a college clinic when a student comes in and says, "I think I have a migraine. My head hurts, I cannot stand the bright light, and I feel sick to my stomach." What additional finding is most concerning?
Positive Romberg sign
A subnormal temperature
An ill college roommate
Positive Brudzinski sign
The Correct Answer is D
A. A positive Romberg sign (difficulty maintaining balance with eyes closed) can indicate a neurological issue, but it is not directly associated with a migraine.
B. A subnormal temperature (low body temperature) is not typically associated with migraines and may indicate another issue, but it is not as concerning as other findings.
C. An ill college roommate might suggest a viral illness, but it is not a direct concern for the student’s migraine. Migraines are not contagious, and other signs of illness would be more concerning.
D. Positive Brudzinski sign, which involves involuntary flexion of the hips and knees when the neck is flexed, is indicative of meningeal irritation, a sign of meningitis. This is a medical emergency and much more concerning than the symptoms of a migraine. The student should be further assessed for signs of meningitis, which requires urgent treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client should not sit upright in a chair for prolonged periods (such as 4 hours at a time) immediately following spinal fusion, as this could place excessive strain on the surgical site. The client should be assisted to sit upright for short periods and be repositioned regularly.
B. Clear drainage on the spinal dressing could indicate cerebrospinal fluid leakage, which is a concern following spinal surgery. The nurse should expect minimal to no drainage, and if clear fluid is observed, it should be reported immediately.
C. Elevating the client's legs when lying on his side may not be necessary unless specifically ordered by the healthcare provider. In general, the client should maintain proper body alignment and avoid any positions that strain the surgical site.
D. Log rolling is a critical intervention for spinal fusion patients to prevent twisting of the spine. The nurse should assist the client in log rolling every 2 hours to maintain spinal alignment and prevent injury to the surgical site.
Correct Answer is B
Explanation
A. Sleeping more during the day than nighttime is not a typical manifestation of primary dementia. While changes in sleep patterns can occur in individuals with dementia, the hallmark features are related to cognitive decline and memory loss, not excessive daytime sleep.
B. Forgetfulness gradually progressing to disorientation is a classic manifestation of primary dementia, particularly Alzheimer's disease. This condition is characterized by progressive memory loss, confusion, and eventually, disorientation.
C. Temporary, reversible loss of brain function is not characteristic of primary dementia. Dementia is typically a progressive and irreversible decline in cognitive function, with symptoms worsening over time.
D. Hypervigilant behaviors are not typically associated with primary dementia. Instead, individuals with dementia may experience confusion, apathy, or withdrawal, but hypervigilance is more commonly associated with conditions such as anxiety or paranoia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.