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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.
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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.
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
- A. Do you live in a crowded residence?
- B. When was your last tetatuss vaccination?
- C. Have you had any viral infections recently?
- D. Have you had any viral infections in the last month?
Correct Answer: A
Rationale: Living in a crowded residence increases the risk of bacterial meningitis due to close contact and potential spread of infection. Questions about tetanus vaccination or recent viral infections are less relevant to the focused history for bacterial meningitis.
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
- A. Bleeding
- B. Hoarseness
- C. Dyspnea
- D. Dysphagia
- E. Seizures
Correct Answer: B,C,D
Rationale: Common complications of vagal nerve stimulation device implantation include hoarseness (most common), dyspnea, neck pain, and dysphagia. Bleeding is not a common complication, and seizures are not typically a post-procedure complication.
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 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.