Nokea
Which symptom is specific to migraine headaches?
- A. Tachycardia
- B. They become worse in the evening
- C. They involve the entire head
- D. They are preceded by an aura
Correct Answer: D
Rationale: Migraine headaches are unusual in that signs and symptoms occur before the acute attack.
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Which Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
- A. 8
- B. 10
- C. 11
- D. 12
Correct Answer: D
Rationale: The Glasgow Coma Scale was developed in 1974, and it consists of three parts of the neurologic assessment: eye opening, best motor response, and best verbal response. This patient gets a 4 for eye opening, a 2 for incomprehensible speech, and a 6 for moving on demand.
The nurse explains to a patient and family that the triad of signs of Parkinson disease is: ___, rigidity, and bradykinesia.
Correct Answer: tremor
Rationale: Tremor, rigidity, and bradykinesia are the triad that make up the signs of Parkinson disease.
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. Which is the appropriate nursing response to this finding?
- A. Cleanse nose with a soft cotton-tipped swab.
- B. Gently suction the nasal cavity.
- C. Gently wipe nose with absorbent gauze.
- D. Ask patient to blow his nose.
Correct Answer: C
Rationale: The patient's ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not mucus.
Which food should the person who experiences migraine headaches avoid?
- A. Yogurt
- B. Caffeine
- C. Beef
- D. Pears
- E. Marinated foods
- F. Milk
Correct Answer: A,B,E
Rationale: Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork.
Which technique is necessary for safely feeding a patient with hemiplegia?
- A. Mixing liquids and solid foods together
- B. Taking the patient's dentures out to prevent choking
- C. Checking the affected side of mouth for food accumulation
- D. Offering small bites of food
- E. Elevating the patient to no more than 30 degrees
- F. Adding a thickening agent to liquids
Correct Answer: C,D,F
Rationale: Important nursing measures include avoiding foods that cause choking, checking the affected side of the mouth for accumulation of food and resultant poor hygiene, not mixing liquids and solid foods, and encouraging the patient to take small bites.