Nokea
The client with a history of migraine headaches comes to the clinic and reports that a migraine is coming because the client is experiencing bright spots before the eyes. Which phase of migraine headaches is the client experiencing?
- A. Prodrome phase.
- B. Aura phase.
- C. Headache phase.
- D. Recovery phase.
Correct Answer: B
Rationale: Bright spots are visual auras (B), a sensory warning preceding migraines. Prodrome (A) involves mood changes, headache (C) is pain, and recovery (D) follows pain.
You may also like to solve these questions
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.
When the nurse observes that the client has difficulty swallowing the capsule of medication, which action is best to take?
- A. Soak the capsule in water until soft.
- B. Tell the client to chew the capsule.
- C. Moisten the capsule in the client's mouth.
- D. Offer water before giving the capsule.
Correct Answer: D
Rationale: Offering water before giving the capsule aids swallowing without altering the medication's integrity.
The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially?
- A. Right hemiparesis
- B. Expressive aphasia
- C. Poor impulse control
- D. Tetraplegia
Correct Answer: C
Rationale: A stroke affecting the right hemisphere may produce left, not right hemiparesis. Motor fibers in the brain cross over in the medulla before entering the spinal column. This client may or may not have aphasia because the center for language is located on the left side of the brain in 75% to 80% of the population; this client had a stroke involving the right hemisphere. Even though the client may have expressive aphasia, it is more important to assess for poor impulse control due to the risk for injury. The client with a stroke affecting the right side of the brain often exhibits impulsive behavior and is unaware of the neurological deficits. Poor impulse control increases the client’s risk for injury. Tetraplegia (quadriplegia) is associated with an SCI; tetraplegia usually does not occur from a stroke.
The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?
- A. Displacement of brain tissue
- B. Increase in cerebral perfusion
- C. Increase in the serum pH level
- D. Leakage of cerebrospinal fluid
Correct Answer: A
Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased perfusion. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.
The nurse is caring for the client who has limited intake due to dysphagia following an ischemic stroke. Which serum laboratory result should the nurse review to verify that the client is dehydrated?
- A. Elevated serum creatinine
- B. Elevated blood urea nitrogen
- C. Decreased hemoglobin
- D. Decreased prealbumin
Correct Answer: B
Rationale: The serum creatinine is elevated with renal insufficiency or renal failure. The BUN is elevated when the client is dehydrated due to the lack of fluid volume to excrete waste products. The Hgb is decreased with blood loss or anemia from nutritional deficiencies, not with dehydration. A decreased prealbumin indicates a nutritional deficiency.