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A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- A. Ipsilateral tearing
- B. Miosis
- C. Rhinorrhea
- D. Neck and shoulder tenderness
- E. Eyelid edema
Correct Answer: A,B,E
Rationale: Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
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A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Lip smacking
- B. Sudden loss of muscle tone
- C. Brief jerking of the extremities
- D. Picking at clothing
- E. Staring spell
Correct Answer: A,D,E
Rationale: Absence seizures are characterized by brief lapses in attention, often with staring spells, lip smacking, or picking at clothing. Sudden loss of muscle tone is more typical of atonic seizures, and brief jerking of extremities is associated with myoclonic seizures.
A nurse is teaching a client who experiences migraine headaches. Which statement should the nurse include in the teaching to help prevent the onset of migraine headaches?
- A. Wear dark sunglasses when you are in brightly lit spaces.
- B. Lie down in a darkened room when you experience a headache.
- C. Set your alarm to ensure you do not sleep longer than 6 hours at one time.
- D. Take over-the-counter pain relievers as soon as the headache starts.
Correct Answer: B
Rationale: At the onset of a migraine attack, lying down in a darkened room can alleviate pain. The client may cover both eyes and use a cool cloth on the forehead. If the client falls asleep, they should remain undisturbed. The other options are not recognized therapies for migraines.
A nurse plans care for a client with epilepsy. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
- A. Keep bed rails up at all times.
- B. Maintain the client on strict bedrest.
- C. Ensure that the client has IV access.
- D. Provide a high-protein diet.
- E. Keep oxygen and suction equipment available.
Correct Answer: A,C,E
Rationale: Oxygen and suctioning equipment with an airway must be readily available. Bed rails should be up at all times to prevent injury from a fall during a seizure. A saline lock provides venous access for IV drug therapy to manage seizures. Padded tongue blades are dangerous, dietary restrictions are not indicated, and strict bedrest is not necessary.
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
- A. Photophobia
- B. Dilated pupils
- C. Headache
- D. Widened pulse pressure
- E. Bradycardia
Correct Answer: B,D,E
Rationale: Increased ICP in encephalitis is indicated by dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are symptoms of encephalitis but not specific to increased ICP.
After teaching a client newly diagnosed with spieplety, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. I will drink more water daily to prevent my mouth from getting dry.
- B. This medication will stop me from getting an aura before a seizure.
- C. I will not drive a motor vehicle while taking this medication.
- D. Even when my seizure stop I will continue to take this drug.
Correct Answer: D
Rationale: Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.