1. The nurse is caring for a client experiencing migraine headaches who is receiving a beta blocker to help manage this disorder. When preparing a teaching plan, which instruction does the nurse plan to provide?

ANS: B

Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss an appropriate use of the medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

2. The nurse is assessing a client with a history of migraines. Which clinical manifestation is an early sign of a migraine with aura?

ANS: C

Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 928

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is reviewing a client’s prescription for sumatriptan succinate (Imitrex). Which condition in this client’s medical history does the nurse report to the health care provider?

ANS: C

Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal’s angina. The other conditions would not affect the client’s treatment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Analysis)

4. The nurse is assessing a client with a cluster headache. Which clinical manifestation does the nurse expect to find?

ANS: A

Cluster headache is usually accompanied by ipsilateral tearing, rhinorrhea or nasal congestion, ptosis, eyelid edema, facial sweating, and miosis. The other manifestations are not associated with cluster headaches.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 931

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity?

ANS: D

Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. The other seizures do not manifest in this manner.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 932

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Communication and Documentation

6. The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for?

ANS: A

Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, patting, and picking at clothing. The other manifestations do not correlate with absence seizures.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 932

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)