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A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol?
- A. Alcohol causes hormone fluctuations.
- B. Alcohol causes vasodilation of the blood vessels.
- C. Alcohol has an excitatory effect on the CNS.
- D. Alcohol diminishes endorphins in the brain.
Correct Answer: B
Rationale: Alcohol's vasodilatory effect can worsen migraines. It depresses the CNS, does not affect hormones significantly, and does not reduce endorphins in this context.
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The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
- A. Change the patients position as indicated.
- B. Monitor serum electrolytes.
- C. Maintain NPO status.
- D. Monitor arterial blood gas (ABG) values.
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP?
- A. Disorientation and restlessness
- B. Decreased pulse and respirations
- C. Projectile vomiting
- D. Loss of corneal reflex
Correct Answer: A
Rationale: Disorientation and restlessness are early signs of increased ICP. Decreased pulse, vomiting, and loss of reflexes are later manifestations.
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
- A. Rizatriptan (Maxalt)
- B. Naratriptan (Amerge)
- C. Sumatriptan succinate (Imitrex)
- D. Zolmitriptan (Zomig)
Correct Answer: C
Rationale: Sumatriptan and other triptans can cause chest pain and are contraindicated in ischemic heart disease. All listed medications are triptans, but sumatriptan is specifically noted for this risk.
The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient?
- A. Prednisone
- B. Dexamethasone
- C. Cafergot
- D. Phenytoin
Correct Answer: D
Rationale: Phenytoin is used prophylactically post-supratentorial surgery to prevent seizures. Prednisone and dexamethasone are steroids, and Cafergot treats migraines.