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The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Nausea
- C. Photophobia
- D. Fever
- E. Nuchal rigidity
- F. Vomiting
Correct Answer: A,B,C,F
Rationale: Migraine headaches typically present with unilateral pain, nausea, photophobia, and vomiting.
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A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving at the hospital, the paramedic notices clear fluid draining from the patient's nose. Having seen this before, the paramedic places a drop from the patient's nose onto a piece of gauze. The nurse is looking for a clinical finding that is called the halo's sign. What type of fracture does the paramedic suspect the patient has?
- A. Depressed skull fracture
- B. Traumatic linear skull fracture
- C. Subarachnoid hemorrhage
- D. Basilar skull fracture
Correct Answer: D
Rationale: Halo sign (clear fluid with a yellow ring on gauze) suggests cerebrospinal fluid leak, commonly associated with basilar skull fracture.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 6 of 6
• History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
• Diagnostics Test Results
Head Computed Tomography (CT) scan
1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes.
• Nurses' Notes
1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.
1850: Pain reassessed. Client reports pain 7/10 on the Numerical Rating Scale. Reports persistent nausea.
1852: Physician notified of the findings.
• Orders
1800:
• ketorolac 30 mg intravenous push x 1 dose
• 500 mL of 0.9% sodium chloride (normal saline) over one hour
1900:
• metoclopramide 10 mg intravenous push x 1 dose
• diphenhydramine 25 mg intravenous push x 1 dose
• sumatriptan 6 mg subcutaneous x1 dose
Six hours later, the client recovers and is discharged home. The nurse is teaching the client about newly prescribed intranasal sumatriptan. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I should use this medication as soon as I notice migraine symptoms beginning.
- B. If my migraine does not improve after two hours, I can take a second dose, but no more than 40 mg in 24 hours.
- C. I should avoid using this medication if I experience chest pain or pressure after taking it.
- D. I can use this medication daily to prevent migraines from occurring.
- E. If I experience tingling or flushing after taking this medication, I should go to the emergency room.
- F. I should watch for signs of serotonin syndrome, such as confusion and muscle stiffness.
Correct Answer: A,B,C
Rationale: Using sumatriptan at migraine onset, redosing after 2 hours (with a 40 mg daily limit for intranasal form), and avoiding use with chest pain (due to possible coronary vasospasm) are correct. Daily use is incorrect (sumatriptan is for acute treatment), tingling/flushing are common side effects, and serotonin syndrome is unlikely with sumatriptan alone.
The nurse has received a prescription for a mannitol infusion. Which type of intravenous tubing should be used to administer mannitol?
- A. Microdrip
- B. Filtered
- C. Vented
- D. Non-vented
Correct Answer: B
Rationale: Mannitol is a hyperosmolar diuretic that can crystallize in IV tubing, potentially causing blockages. Filtered tubing is required to prevent crystals from entering the bloodstream, ensuring safe administration. Microdrip, vented, and non-vented tubing do not address this risk.
This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response?
- A. Decreased mood lability
- B. Steady gait
- C. Urinary continence
- D. Increased bone mass
Correct Answer: B
Rationale: Carbamazepine is an anticonvulsant used for seizures, and a steady gait indicates reduced seizure activity or improved neurological stability. Mood lability, urinary continence, and bone mass are not primary therapeutic outcomes.
The nurse is caring for a client following a stroke. The client can understand instructions but is unable to express himself verbally. The nurse anticipates that this stroke has impacted which lobe of the client's brain?
- A. Frontal lobe
- B. Parietal lobe
- C. Temporal lobe
- D. Occipital lobe
Correct Answer: A
Rationale: Expressive aphasia is associated with frontal lobe stroke, particularly Broca's area.