Nokea
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
- A. Complaint of headache off and on for past month
- B. No bowel movement since yesterday
- C. Nausea
- D. Frequent voiding
Correct Answer: C
Rationale: Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for the past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.
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The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
- A. Apply cool or warm cloth to head or eyes.
- B. Eliminate use of bright lights when working.
- C. Avoid certain foods.
- D. Perform stretching exercises and frequent position changes.
Correct Answer: D
Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches.
An older adult client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?
- A. Becoming confused during the night
- B. Drooling from side of mouth
- C. Bruit heard over carotids
- D. Irregular heart rhythm
Correct Answer: B
Rationale: Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA. It is not unusual for older adult clients to become confused when placed in a new environment and would indicate a need for further assessment. Bruits over the carotids may indicate altered blood flow to the brain but may not be a new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or other cardiac disorders.
A female client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?
- A. Cluster headaches can cause severe debilitating pain.
- B. Migraines often coincide with menstrual cycle.
- C. Tension headaches are easier to treat.
- D. Headaches are the most common type of reported pain.
Correct Answer: B
Rationale: Changes in reproductive hormones as found during the menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain, but this is not the reason for tracking. Tension headaches can be managed, but this is not associated with a monthly calendar. Headaches are common, but that is not the reason for tracking.
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.
- A. Left-sided hemiplegia
- B. Tendency to distractibility
- C. Impairment of long-term memory
- D. Hyperaware of deficits
- E. Neglect of objects and people on the left side
Correct Answer: A,B,E
Rationale: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside-down and right-side up; impairment of short-term memory; and neglect left side of body, objects and people on left side.
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?
- A. Reduces hypotension
- B. Increases appetite
- C. Relaxes muscles
- D. Relieves migraines
Correct Answer: C
Rationale: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension.