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The nurse is caring for a hospitalized patient who has a moderate bilateral headache that radiates from the base of the skull. Which of the following prescribed PRN medications should the nurse administer initially?
- A. Lorazepam
- B. Acetaminophen
- C. Morphine sulphate
- D. Butalbital and Aspirin
Correct Answer: B
Rationale: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulphate or butalbital and Aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
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The health care provider is considering the use of sumatriptan for a patient with migraine headaches. Which of the following information obtained by the nurse is most important to report to the health care provider?
- A. The patient has at least 1-2 cups of coffee daily.
- B. The patient has had migraine headaches for 30 years.
- C. The patient has a history of a recent acute myocardial infarction.
- D. The patient has been taking topiramate for 2 months.
Correct Answer: C
Rationale: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.
Which of the following prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
- A. Give phenytoin 100 mg IV.
- B. Monitor level of consciousness.
- C. Obtain computed tomography scan.
- D. Administer lorazepam 4 mg IV.
Correct Answer: D
Rationale: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure drugs such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
The nurse is teaching a patient about management of migraine headaches. Which of the following patient statements indicates that the teaching has been effective?
- A. I will take the topiramate as soon as any headaches start.
- B. I should avoid taking Aspirin and sumatriptan at the same time.
- C. I will try to lie down in a dark and quiet area when the headaches begin.
- D. A glass of wine might help me relax and prevent headaches from developing.
Correct Answer: C
Rationale: It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
The nurse is obtaining a health history and physical assessment from a patient with possible multiple sclerosis (MS). Which of the following assessment should the nurse include?
- A. Assess for the presence of chest pain.
- B. Inquire about any urinary tract problems.
- C. Inspect the skin for rashes or discoloration.
- D. Question the patient about any increase in libido.
Correct Answer: B
Rationale: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
Which of the following parameters should the nurse assess when caring for a patient who is experiencing a cluster headache?
- A. Nuchal rigidity
- B. Projectile vomiting
- C. Unilateral eyelid swelling
- D. Throbbing, bilateral facial pain
Correct Answer: C
Rationale: Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.