ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 38 : Caring for Clients With Cerebrovascular Disorders Questions
Question 1 of 5
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?
Correct Answer: 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.
Question 2 of 5
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?
Correct Answer: 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.
Question 3 of 5
The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
Correct Answer: 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.
Question 4 of 5
A client who has experienced an initial transient ischemic attack (TIA) states: 'I'm glad it wasn't anything serious.' Which is the best nursing response to this statement?
Correct Answer: D
Rationale: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
Question 5 of 5
The nurse is assessing a client for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests that the client is experiencing a TIA?
Correct Answer: A
Rationale: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.