Nokea
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.
You may also like to solve these questions
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.
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.
A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply.
- A. Balloon angioplasty of the carotid artery followed by stent placement
- B. Removal of the carotid artery
- C. Percutaneous transluminal coronary artery angioplasty
- D. Carotid endarterectomy
- E. Administration of tissue plasminogen activator
Correct Answer: A,D
Rationale: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain.
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.
A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client?
- A. Identify and avoid factors that precipitate or intensify an attack.
- B. Keep a record of activities following an attack.
- C. When an attack occurs, stay in a brightly lit area.
- D. Write down any adverse drug effects.
Correct Answer: A
Rationale: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs whenever possible.