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1. The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate? A. Using the Romberg test B. Observing the reaction of pupils to light C. Observing the client's response to painful stimuli D. Monitoring the client's sensitivity t...

1. The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate? A. Using the Romberg test B. Observing the reaction of pupils to light C. Observing the client's response to painful stimuli D. Monitoring the client's sensitivity to temperature, touch, and pain ANS: C Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client’s response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client’s pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response. 2. A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate? A. Measure the heart and the pulse rate. B. Provide the client with caffeine-rich drinks. C. Allow the client to wash hair and rest D. Measure the level of consciousness (LOC) of the client. ANS: C Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider. The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: A. musculoskeletal system. B. sympathetic nervous system. C. parasympathetic nervous system. D. endocrine system. ANS: B Rationale: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of thesympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes. 8. The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve? A. II B. VI C. VIII D. XI ANS: C Rationale: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement. 10. Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin “slice” of a muscular body area? A. Computed tomography (CT) B. Magnetic resonance imaging (MRI) C. Positron emission tomography (PET) D. Single-photon emission computed tomography (SPECT) ANS: A Rationale: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or “slices,” of the body. An MRI usesradiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow. 11. The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern? A. The HCP maintains aseptic procedure. B. The pressure is noted to be 90 mm H20. C. The cerebrospinal fluid (CSF) is cloudy in nature. D. The HCP administers a drug by intrathecal injection. ANS: C Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H20, the client’s CSF fluid pressure falls within normal limits (between 80 and 100 mm H20). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern. 12. A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply? A. Acetone B. A special soapC. Shampoo D. Warm water ANS: C Rationale: Shampoo is used to remove the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste. 14. A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do? A. Touch nose with one finger. B. Close eyes and stand erect. C. Close eyes and discriminate between dull and sharp. D. Close eyes and jump on one foot. ANS: B Rationale: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance. 15. The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client? A. That it is not necessary to worry about the finer details of the disease. B. That because there is so much to learn, there will be another meeting to discuss it again. C. That the covering is called myelin and that it can be discussed further at the next meeting. D. That the disease process requires more research. ANS: CRationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known. 17. The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse shouldassess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Moving the head toward both sides B. Lightly tapping the lower portion of the neck to detect sensation C. Moving the head and chin toward the chest D. Gently pressing the bones on the neck ANS: C Rationale: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not assessed. 18. The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? A. Comatose B. Somnolence C. Stupor D. Normal ANS: A Rationale: The GSC is used to measure the LOC. The scale consists of three parts: eyeopening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC. 19. A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client? A. Lumbar puncture B. Echoencephalography C. Nerve conduction studies D. EMG ANS: A Rationale: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles. The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? A. Cranial nerve I B. Cranial nerve V C. Cranial nerve XI D. Cranial nerve XII ANS: D Rationale: Assessment of the movement of the tongue is related to cranial nerve XII, the hypoglossal nerve. Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement. 21. The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, “What do you want?” Which level of consciousness should the nurse document? A. Conscious B. Semicomatose C. Somnolent D. Stuporous ANS: C Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that isconscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli. 22. The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention? A. a score of 9 B. A score of 11 C. A score of 12 D. A score of 15 ANS: A Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range. 23. The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply. A. Unequal pupils B. Pupil reaction quick C. Pinpoint pupils D. Absence of pupillary response E. Pupil reacts to lightANS: A, C, D Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment. ANS: B Rationale: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period. PTS: 1 REF: p. 603, Nursing Process for the Client Undergoing Neurologic Testing NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential 26. The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? A. Flaccidity B. Abnormal posture C. Weak muscular tone D. Decorticate posturing ANS: A Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5;therefore, weak muscular tone is not the most appropriate documentation. 28. The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply. A. Place a warm cotton ball on the client’s arm. B. Use a safety pin to stroke the client’s fingers. C. Use a needle to introduce a prick to the client’s skin.D. Drag a tube filled with cold water on the client’s arm. E. Place a tube filled with warm water on the client’s hand. ANS: A, B, D, E Rationale: The nurse evaluates the extremities for sensitivity to heat, cold, touch, and pain. Various objects can be used by the nurse for this purpose, including cotton balls and tubes filled with hot or cold water. Sharp objects may be used but should not pierce the skin; therefore, it is appropriate for the nurse to stroke the client’s fingers with a safety pin but not to prick the skin with a needle. 29. A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? A. Administer antihistamines to the client. B. Provide adequate caffeine-rich drinks to the client. C. Leave the client to rest and do not perform any assessments. D. Position the client flat as directed. ANS: D Rationale: A client who has undergone a lumbar puncture should be positioned flat and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation Nervous System Disorders 1. A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Restrain the client during the seizure. B. Insert a tongue blade between the teeth. C. Protect the client from injury. D. Suction the mouth during the convulsion. ANS: C Rationale: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure. 4. The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop? A. Damage to the nerves that facilitate vision and hearing B. Damage to the vagal nerve C. Damage to the olfactory nerve D. Damage to the facial nerve ANS: A Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve. 5. The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? A. Assess client's reaction to new medication schedule. B. Administer medications at exact intervals ordered. C. Document medication given and dose. D. Give client plenty of fluids with medications. ANS: B Rationale: The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client. 7. The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child? A. An absence seizure B. A myoclonic seizure C. A partial seizure D. A tonic-clonic seizure ANS: A Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic- clonic seizures involve jerking movements. 9. A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A. Blood pressure 100/60 mm Hg B. Lethargy C. Nausea D. Periorbital edema ANS: B Rationale: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP. 10. The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply. A. Stiff neck B. Generalized pain C. Glasgow Coma Scale of 15 D. Elevated systolic blood pressureE. Brisk pupil response F. Wide pulse pressure ANS: D, F Rationale: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings. 11. A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Dextrose 5% in water (D5W) B. Half-normal saline (0.45% NSS) C. One-third normal saline (0.33% NSS) D. Lactated Ringer’s ANS: D Rationale: With increasing ICP, isotonic normal saline, lactated Ringer’s, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP. 12. A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Elevate the head of the bed. B. Complete a head-to-toe assessment. C. Administer morning dose of anticonvulsant. D. Administer Percocet as ordered. ANS: A Rationale: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues. 13. The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply. A. Cloudy cerebral spinal fluid B. Pain and stiffness of the extremities C. Purpura of hands and feet D. Low white blood cell (WBC) count E. Low red blood cell (RBC) count F. Low antidiuretic hormone (ADH) levels ANS: A, C Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected. 14. The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which assessment finding by the nurse would be most significant in the diagnosis of this client? A. Change in level of consciousness B. Vomiting C. Vector bites D. Seizures ANS: C Rationale: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in level of consciousness (LOC), vomiting, and seizures are all symptoms of increased intracranial pressure (ICP) and do not assist in the differentiating of cause, diagnosis, or establishing nursing care. 15. A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess? A. Sleep pattern B. Mood and affect C. Appetite D. Muscle spasms ANS: D Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug. 16. The nurse is caring for a 30-year-old client diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? A. “I will have progressive muscle weakness.” B. “I will lose strength in my arms.” C. “My children are at greater risk to develop this disease.” D. “I need to remain active for as long as possible.” ANS: C Rationale: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications. 17. The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client? A. Avoid stimuli that trigger pain. B. Use ophthalmic lubricant and protect the eye. C. Encourage semiannual dental exams. D. Complete the course of antibiotics as prescribed. ANS: B Rationale: The VII cranial nerve supplies muscles to the face. In Bell palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux(cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus. 18. The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client? ? A. Involvement with diversion activities B. Enhancement of the immune system C. Establishing balanced nutrition D. Maintaining a safe environment ANS: D Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority. 20. A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A. Insert an airway or bite block. B. Manually restrain the extremities. C. Turn client to side-lying position. D. Monitor vital signs. ANS: C Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase. 21. The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event? A. Seizure began at 1300 hours. B. The client cried out before the seizure began. C. Seizure was 1 minute in duration including tonic-clonic activity. D. Sleeping quietly after the seizure ANS: C Rationale: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and the skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity. 22. A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. A. Medication regimen B. Appointments for chemotherapy or radiotherapy C. Adverse effects of chemotherapy or radiation and techniques for managing them D. Nutritional support E. Electromyography ANS: A, B, C, D Rationale: The nurse should include the medication regimen, appointments for chemotherapy and radiotherapy, adverse effects of chemotherapy or radiation andtechniques for managing them, and nutritional support as components of the discharge teaching for this client. Electromyography is used in amyotrophic lateral sclerosis (ALS) to validate weakness in the affected muscles and should not be included for the client being discharged after surgery for a brain tumor. 25. Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? A. The client will take the seizure medication at the same time daily. B. The client will remain free of injury if a seizure does occur. C. The client will verbalize an understanding of feelings that preempt seizure activity. D. The client will post emergency numbers on the refrigerator for ease of obtaining. ANS: B Rationale: All of the goals are appropriate, but the most important goal is the long- term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care. 2. A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? A. Avoid crowds. B. Take drugs only after meals at night. C. Avoid caffeine and alcohol. D. Use caution while driving or performing hazardous activities. ANS: D Rationale: A client who is prescribed an antileptic needs to exercise caution while driving and avoid performing hazardous activities. A client taking non-steroidal anti- inflammatory drugs should be advised against taking caffeine and alcohol. The clientneed not take the drug only at night after meals or be instructed to avoid crowds. 4. A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A. Reduces hypotension B. Increases appetite C. Relaxes musclesD. Relieves migraines ANS: C Rationale: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension. 5. A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client? A. Identify and avoid factors that precipitate or intensify an attack. B. Keep a record of activities following an attack. C. When an attack occurs, stay in a brightly lit area. D. Write down any adverse drug effects. ANS: A Rationale: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs whenever possible. 6. While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? A. Migraine B. Tension C. Cluster D. Sinus ANS: C Rationale: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed. 9. A female client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? A. Cluster headaches can cause severe debilitating pain. B. Migraines often coincide with menstrual cycle. C. Tension headaches are easier to treat. D. Headaches are the most common type of reported pain. ANS: B Rationale: Changes in reproductive hormones as found during the menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain, but this is not the reason for tracking. Tension headaches can be managed, but this is not associated with a monthly calendar. Headaches are common, but that is not the reason for tracking. 10. The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms? A. Apply cool or warm cloth to head or eyes. B. Eliminate use of bright lights when working.C. Avoid certain foods. D. Perform stretching exercises and frequent position changes. ANS: D Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches. 21. A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? A. “I use this to prevent migraines.” B. “I take this when I get a headache.” C. “It constricts the blood vessels in my head.” D. “It alleviates my sensitivity to light and sound.” ANS: A Rationale: Sumatriptan is a serotonin receptor agonist that stimulates serotoninreceptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy. 25. The nurse is completing an assessment on a client with a history of migraines. The nurse would identify factor(s) as a possible trigger for a migraine headache? Select all that apply. A. Red wine B. Nausea C. Menstruation D. Exposure to flashing light E. Change in environmental temperature F. Prolonged positioning ANS: A, C, D Rationale: Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation), exposure to flashing light, and particular food/beverages and alcohol can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to changes in environmental temperature does not trigger a migraine headache. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches.