Nokea
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
- A. I use this to prevent migraines.
- B. I take this when I get a headache.
- C. It constricts the blood vessels in my head.
- D. It alleviates my sensitivity to light and sound.
Correct Answer: A
Rationale: Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
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A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which factor(s) to be true? Select all that apply.
- A. Symptoms no longer evolving
- B. Presence of an ischemic stroke
- C. Used concurrently with heparin therapy
- D. Administered intramuscularly for faster response
- E. Administered within 3 hours of onset of symptoms
- F. Administered for hemorrhagic strokes
Correct Answer: B,E
Rationale: TPA is a thrombolytic agent that can limit neurologic${{content}} neurologic deficits if given IV within 3 hours of onset of an ischemic CVA. Waiting for symptoms to stabilize (no longer evolving) may take days and would not be appropriate for the use of TPA. TPA is not used in conjunction with other anticoagulants and would never be used to treat a hemorrhagic stroke (promotes more bleeding).
Which nursing assessment finding is most indicative of a hemorrhagic stroke?
- A. Client history of atrial fibrillation
- B. Sudden onset of breathing alterations
- C. Symptoms evolving over 24 to 48 hours
- D. Client history of hyperlipidemia
Correct Answer: B
Rationale: Hemorrhagic strokes are less common than ischemic strokes and usually present with sudden onset and have the most impact on breathing, blood pressure, and heart rate. Client history of atrial fibrillation and hyperlipidemia are most significant with ischemic strokes caused by embolus or plaque. Ischemic strokes tend to evolve over 24 to 48 hours until symptoms complete.
A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
- A. Avoid heavy lifting.
- B. Avoid fiber in the diet.
- C. Take an antacid frequently.
- D. Take an herbal form of feverfew.
Correct Answer: A
Rationale: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.
The nurse is assessing a client for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests that the client is experiencing a TIA?
- A. Impaired muscle coordination
- B. Respiratory distress
- C. Severe headache
- D. Nausea and vomiting
Correct Answer: A
Rationale: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.
While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?
- A. Migraine
- B. Tension
- C. Cluster
- D. Sinus
Correct Answer: C
Rationale: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed.