Medical-Surgical Question 1: A 58-year-old patient presents with consistently high blood pressure readings. The patient reports occasional headaches and shortness of breath. What is the most likely diagnosis?

A) Diabetes
B) Migraine
C) Hypertension
D) Asthma

Explanation: The most likely diagnosis for this patient is hypertension, as indicated by consistently high blood pressure readings. Hypertension, or high blood pressure, is a common medical condition that is often asymptomatic but can lead to serious complications such as heart disease, stroke, and kidney problems. The occasional headaches and shortness of breath reported by the patient are potential symptoms of hypertension-related issues. Early diagnosis, lifestyle modifications, and medication management are essential for controlling hypertension and reducing the risk of complications.

Correct Answer:

Select an answer C) Hypertension

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Medical-Surgical Question 2: A 14-year-old patient presents with chronic cough, recurrent lung infections, and difficulty breathing. The patient’s sweat chloride test results are elevated. What is the most likely diagnosis?

A) Asthma
B) Pneumonia
C) Cystic Fibrosis
D) Bronchitis

Explanation: The most likely diagnosis for this patient is Cystic Fibrosis (CF). CF is a genetic disorder that affects the respiratory, digestive, and sweat glands. The chronic cough, recurrent lung infections, and elevated sweat chloride test results are typical features of CF. Early diagnosis and comprehensive care are essential for managing this condition.

Correct Answer:

Select an answer C) Cystic Fibrosis

Medical-Surgical Nursing Questions: Hypertension Treatments

Medical-Surgical Question 3: A 30-year-old patient presents with sudden chest pain, shortness of breath, and decreased breath sounds on one side of the chest. On physical examination, you note chest asymmetry with the affected side appearing smaller. What is the most likely diagnosis?

A) Pneumonia
B) Bronchitis
C) Pneumothorax
D) Pulmonary Embolism

Explanation: The most likely diagnosis for this patient is C) Pneumothorax. Pneumothorax is a condition where air accumulates in the pleural space, causing lung collapse. It often presents with sudden chest pain, shortness of breath, decreased breath sounds on the affected side, and chest asymmetry. Early recognition and appropriate intervention, such as chest tube placement, are essential to treat pneumothorax.

Correct Answer:

Select an answer C) Pneumothorax

Medical-Surgical Question 4: A 25-year-old patient who has just undergone a central venous catheter insertion develops sudden difficulty breathing, chest pain, and cyanosis. On examination, you notice decreased breath sounds on one side of the chest. What is the most likely diagnosis?

A) Pneumonia
B) Bronchitis
C) Tension Pneumothorax
D) Pulmonary Embolism

Explanation: The most likely diagnosis for this patient is C) Tension Pneumothorax. Tension pneumothorax is a life-threatening condition that occurs when air accumulates in the pleural space, leading to lung collapse and increasing pressure on the heart and great vessels. It presents with sudden difficulty breathing, chest pain, cyanosis, and decreased breath sounds on one side. Immediate intervention, such as needle decompression, is required to relieve the pressure and save the patient’s life.

Correct Answer:

Select an answer C) Tension Pneumothorax

Medical-Surgical Nursing Questions Focus on Hypertension: Causes and Diagnosis

Medical-Surgical Question 5: A 55-year-old patient who recently underwent lung surgery has a chest tube in place. The nurse observes continuous bubbling in the water-seal chamber of the chest drainage system. What should the nurse do? Hypertension

A) Clamp the chest tube
B) Increase the suction pressure
C) Assess for an air leak
D) Remove the chest tube

Explanation: The nurse should assess for an air leak. Continuous bubbling in the water-seal chamber indicates an air leak in the system, which needs immediate attention. Clamping the chest tube or removing it would not address the underlying issue and can be harmful. Increasing suction pressure is not indicated until the source of the air leak is identified.

Correct Answer:

Select an answer C) Assess for an air leak

Medical-Surgical Nursing Questions Focus on Hypertension: Medications

Medical-Surgical Question 6: A patient with a chest tube complains of severe pain at the insertion site. The nurse notes subcutaneous emphysema around the site. What is the nurse’s priority action?

A) Administer pain medication
B) Remove the chest tube
C) Notify the healthcare provider
D) Apply a cold compress

Explanation: The nurse’s priority action is to notify the healthcare provider. Severe pain at the insertion site and subcutaneous emphysema may indicate a complication related to the chest tube, such as tube displacement or an air leak. Prompt evaluation by the healthcare provider is essential to address the issue appropriately.

Correct Answer:

Select an answer C) Notify the healthcare provider

Medical-Surgical Nursing Questions: Understanding Hypertension Causes and Symptoms

Medical-Surgical Question 7: A patient’s chest tube drainage system has suddenly stopped fluctuating, and the chest tube appears kinked. What should the nurse do?

A) Administer pain medication
B) Remove the chest tube
C) Unkink the tube
D) Increase the suction pressure

Explanation: The nurse should unkink the tube. A kink in the chest tube can obstruct drainage, potentially causing complications. The nurse should gently straighten the tube to restore proper flow. Administering pain medication, removing the chest tube, or increasing suction pressure would not address the immediate issue.

Correct Answer:

Select an answer C) Unkink the tube

Understanding Hypertension: Causes and Symptoms

Medical-Surgical Question 8: A 45-year-old patient is scheduled for a bronchoscopy. The patient asks the nurse about the purpose of the procedure. What is the primary purpose of bronchoscopy?

A) To assess cardiac function
B) To examine the esophagus
C) To visualize the airways and lungs
D) To assess kidney function

Explanation: The primary purpose of bronchoscopy is to visualize the airways and lungs. It is a procedure that involves inserting a flexible tube with a light and camera through the mouth or nose to examine the bronchial passages and lungs. Bronchoscopy is used for diagnosing and evaluating respiratory conditions and infections.

Correct Answer:

Select an answer C) To visualize the airways and lungs

Understanding Hypertension: Medical-Surgical Nursing Questions

Medical-Surgical Question 9: A patient is scheduled for a pulmonary function test (PFT). What is the purpose of a PFT?

A) To measure blood pressure
B) To evaluate kidney function
C) To assess lung function
D) To diagnose gastrointestinal conditions

Explanation: The purpose of a pulmonary function test (PFT) is to assess lung function. PFTs are a series of non-invasive tests that measure how well the lungs are working, including lung capacity, airway resistance, and gas exchange. They are valuable in diagnosing and monitoring respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), and restrictive lung diseases.

Correct Answer:

Select an answer C) To assess lung function

Medical-Surgical Question 10: A patient is about to undergo a bronchoscopy. What is a key nursing intervention before the procedure to ensure patient safety?

A) Administer a sedative
B) Elevate the head of the bed
C) NPO (Nothing by mouth) status
D) Apply a warm compress to the chest

Explanation: A key nursing intervention before a bronchoscopy is to maintain NPO (Nothing by mouth) status for several hours before the procedure. This reduces the risk of aspiration during the bronchoscopy and ensures patient safety during the examination.

Correct Answer:

Select an answer C) NPO (Nothing by mouth) status

Understanding Hypertension: Medical-Surgical Nursing High Yield Questions

What is the appropriate nursing action if the patient experiences respiratory distress during a bronchoscopy?

A) Continue with the procedure
B) Remove the bronchoscope immediately
C) Notify the healthcare provider
D) Offer the patient water

Explanation: If a patient experiences respiratory distress during a bronchoscopy, the appropriate nursing action is to immediately remove the bronchoscope and provide necessary interventions to address the distress. This may include administering oxygen, positioning the patient for comfort, and notifying the healthcare provider.

Correct Answer:

Select an answer C) Notify the healthcare provider

During a PFT, the patient is instructed to take a deep breath and exhale forcefully. What test component is typically measured during this maneuver?

A) Cardiac output
B) Blood glucose level
C) Forced expiratory volume in one second (FEV1)
D) Liver function

Explanation: During a PFT maneuver where the patient is instructed to take a deep breath and exhale forcefully, the test component typically measured is the Forced expiratory volume in one second (FEV1). FEV1 is a crucial parameter used to assess lung function and diagnose respiratory conditions.

Correct Answer:

Select an answer C) Forced expiratory volume in one second (FEV1)

Medical-Surgical Nursing Questions: Hypertension Questions, Answers and Rationales

A 65-year-old patient with a history of chronic obstructive pulmonary disease (COPD) presents with fever, productive cough, and increased shortness of breath. Chest X-ray reveals consolidation in the right lower lobe. What is the most likely diagnosis?

A) Asthma exacerbation
B) Pneumothorax
C) Pneumonia
D) Lung cancer

Explanation: The most likely diagnosis for this patient is C) Pneumonia. The clinical presentation of fever, productive cough, and consolidation on chest X-ray is consistent with pneumonia, which is an infection of the lung tissue. In this case, the patient’s history of COPD makes them more susceptible to respiratory infections.

Correct Answer:

Select an answer C) Pneumonia

A 50-year-old patient admitted with pneumonia suddenly becomes confused, hypotensive, and febrile. The nurse suspects sepsis. What is the most appropriate nursing action?

A) Administer a sedative
B) Encourage deep breathing exercises
C) Start antibiotic therapy
D) Administer a bronchodilator

Explanation: In a patient with suspected sepsis, the most appropriate nursing action is to start antibiotic therapy immediately. Sepsis is a life-threatening condition caused by an infection that has spread throughout the body. Early administration of appropriate antibiotics is critical to treating sepsis effectively and improving the patient’s chances of recovery.

Correct Answer:

Select an answer C) Start antibiotic therapy

A patient with pneumonia has a productive cough with yellow-green sputum. What type of pneumonia is most likely present?

A) Viral pneumonia
B) Aspiration pneumonia
C) Bacterial pneumonia
D) Fungal pneumonia

Explanation: The presence of yellow-green sputum suggests bacterial pneumonia. Bacterial pneumonia often presents with productive cough and sputum production, which can have various colors, including yellow-green. The color of the sputum can provide clues about the type of infection.

Understanding Hypertension: Medical-Surgical Nursing Priority Questions

Correct Answer:

Select an answer C) Bacterial pneumonia

Which vital sign abnormality is commonly associated with sepsis?

A) Bradycardia
B) Hypertension
C) Hypothermia
D) Tachycardia

Explanation: Tachycardia (fast heart rate) is commonly associated with sepsis. Sepsis often leads to an increased heart rate as the body tries to compensate for the infection and maintain perfusion to vital organs.

Correct Answer:

Select an answer D) Tachycardia

In a patient with pneumonia, which intervention is important to prevent complications such as atelectasis?

A) Encourage deep breathing exercises
B) Administer antipyretic medications
C) Limit fluid intake
D) Restrict mobility

Explanation: To prevent complications such as atelectasis in a patient with pneumonia, it is important to encourage deep breathing exercises. Deep breathing exercises help maintain lung expansion and prevent areas of the lung from collapsing. This is particularly important in patients with pneumonia to maintain adequate oxygenation.

Correct Answer:

Select an answer A) Encourage deep breathing exercises

A 70-year-old patient with pneumonia is prescribed antibiotics. Which antibiotic class is commonly used as the first-line treatment for community-acquired pneumonia?

A) Aminoglycosides
B) Macrolides
C) Cephalosporins
D) Quinolones

Explanation: Macrolides, such as azithromycin and clarithromycin, are commonly used as first-line antibiotics for community-acquired pneumonia due to their effectiveness against common respiratory pathogens.

Correct Answer:

Select an answer B) Macrolides

patient with pulmonary embolism is receiving anticoagulant therapy with warfarin (Coumadin). What is the primary goal of warfarin therapy in this patient?

A) Pain relief
B) Reducing fever
C) Preventing blood clots
D) Lowering blood pressure

Explanation: The primary goal of warfarin therapy in a patient with pulmonary embolism is to prevent blood clots. Warfarin is an anticoagulant that inhibits blood clot formation, reducing the risk of further embolism or clot growth.

Correct Answer:

Select an answer C) Preventing blood clots

A patient with pneumonia presents with severe respiratory distress. The healthcare provider orders oxygen therapy. What oxygen delivery method is most appropriate for this patient?

A) Nasal cannula
B) Simple face mask
C) Venturi mask
D) Non-rebreather mask

Explanation: For a patient with severe respiratory distress, the most appropriate oxygen delivery method is a Non-rebreather mask. It provides the highest oxygen concentration and is used in emergencies when a high oxygen flow rate is needed to maintain oxygenation.

Correct Answer:

Select an answer D) Non-rebreather mask

A patient with suspected pulmonary embolism undergoes a diagnostic test called a V/Q (ventilation-perfusion) scan. What is the purpose of this test?

A) To assess lung function
B) To measure blood pressure
C) To evaluate kidney function
D) To detect blood clots in the lungs

Explanation: The purpose of a V/Q (ventilation-perfusion) scan is to detect blood clots in the lungs. It is a nuclear medicine test that assesses the ventilation (airflow) and perfusion (blood flow) in the lungs, helping to diagnose or rule out pulmonary embolism.

Correct Answer:

Select an answer D) To detect blood clots in the lungs

Understanding Hypertension: Medical-Surgical Nursing Delegation Questions

A patient with pneumonia is prescribed bed rest. What is the rationale behind prescribing bed rest for this patient?

A) To lower blood pressure
B) To promote better sleep
C) To reduce stress
D) To conserve energy and reduce oxygen demand

Explanation: The rationale behind prescribing bed rest for a patient with pneumonia is to conserve energy and reduce oxygen demand. Resting in bed allows the body to allocate more energy and oxygen resources towards fighting the infection and healing, which can aid in recovery.

Correct Answer:

Select an answer D) To conserve energy and reduce oxygen demand

A 45-year-old patient is admitted with ARDS. What is the hallmark symptom of ARDS that the nurse should assess for in this patient?

A) Hypertension
B) Bradycardia
C) Hypoxemia
D) Hyperthermia

Explanation: The hallmark symptom of ARDS is severe hypoxemia (low oxygen levels in the blood). Patients with ARDS often experience rapid and shallow breathing, increased work of breathing, and may require mechanical ventilation to support oxygenation.

Correct Answer:

Select an answer C) Hypoxemia

A patient with ARDS is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). What is the primary purpose of PEEP in this setting?

A) To administer bronchodilators
B) To decrease oxygen concentration
C) To increase the patient’s heart rate
D) To improve oxygenation and recruit collapsed alveoli

Explanation: The primary purpose of PEEP (Positive End-Expiratory Pressure) in mechanical ventilation for ARDS is to improve oxygenation and recruit collapsed alveoli. PEEP helps keep the alveoli open at the end of expiration, preventing them from collapsing, and improves overall oxygen exchange in the lungs.

Correct Answer:

Select an answer D) To improve oxygenation and recruit collapsed alveoli

In a patient with ARDS, which pharmacological intervention is commonly used to reduce inflammation and edema in the lungs?

A) Antibiotics
B) Diuretics
C) Beta-blockers
D) Corticosteroids

Explanation: In patients with ARDS, corticosteroids may be used to reduce inflammation and edema in the lungs. However, their use is often carefully considered, and the decision to administer corticosteroids should be made by a healthcare provider based on the patient’s specific condition and response to treatment.

Correct Answer:

Select an answer D) Corticosteroids

A patient with ARDS is placed in the prone position. What is the rationale for this positioning?

A) To improve patient comfort
B) To facilitate easier communication
C) To reduce the risk of infection
D) To optimize ventilation and oxygenation

Explanation: Placing a patient with ARDS in the prone position is done to optimize ventilation and oxygenation. This positioning helps distribute ventilation more evenly to the posterior lung segments and improves oxygenation in patients with severe respiratory distress.

Correct Answer:

Select an answer D) To optimize ventilation and oxygenation

A patient with ARDS develops a pneumothorax. Which of the following describes a pneumothorax?

A) Accumulation of pus in the pleural cavity
B) Collapse of a lung due to air in the pleural space
C) Inflammation of the pleura
D) Accumulation of fluid in the pleural cavity

Explanation: A pneumothorax is the collapse of a lung due to the presence of air in the pleural space. This condition can further compromise respiratory function in a patient with ARDS and may require intervention, such as chest tube placement.

Correct Answer:

Select an answer B) Collapse of a lung due to air in the pleural space

A 60-year-old patient with a tracheostomy is experiencing increased secretions. Which nursing intervention is essential to maintain airway patency for this patient?

A) Administering bronchodilators
B) Encouraging deep breathing exercises
C) Frequent suctioning of the tracheostomy tube
D) Elevating the head of the bed to 90 degrees

Explanation: To maintain airway patency for a patient with a tracheostomy experiencing increased secretions, frequent suctioning of the tracheostomy tube is essential. This helps remove excess mucus and prevent airway obstruction, ensuring effective breathing.

Correct Answer:

Select an answer C) Frequent suctioning of the tracheostomy tube

A patient with hemothorax presents with chest pain, dyspnea, and decreased breath sounds on one side of the chest. What is the priority nursing action for this patient?

A) Administering pain medication
B) Placing the patient in a semi-Fowler’s position
C) Preparing for a chest tube insertion
D) Administering oxygen therapy

Explanation: The priority nursing action for a patient with hemothorax is to prepare for a chest tube insertion. Hemothorax involves the accumulation of blood in the pleural space, which can lead to respiratory compromise. A chest tube is needed to drain the blood and re-expand the lung.

Correct Answer:

Select an answer C) Preparing for a chest tube insertion

When caring for a patient with a tracheostomy, which of the following actions should the nurse prioritize to prevent infection?

A) Changing the tracheostomy tube daily
B) Avoiding hand hygiene to prevent skin irritation
C) Ensuring proper humidification of inspired air
D) Maintaining aseptic technique during tracheostomy care

Explanation: To prevent infection in a patient with a tracheostomy, maintaining aseptic technique during tracheostomy care is essential. This includes using sterile equipment, sterile gloves, and proper hand hygiene to reduce the risk of introducing pathogens into the airway.

Correct Answer:

Select an answer D) Maintaining aseptic technique during tracheostomy care

In a patient with hemothorax, what is the primary goal of chest tube placement and drainage?

A) Pain relief
B) Removing pleural effusion
C) Preventing infection
D) Restoring negative intrapleural pressure and re-expanding the lung

Explanation: The primary goal of chest tube placement and drainage in a patient with hemothorax is to restore negative intrapleural pressure and re-expand the lung. This allows the lung to function properly and improves respiratory status.

Correct Answer:

Select an answer D) Restoring negative intrapleural pressure and re-expanding the lung

Which of the following is a common complication associated with tracheostomy care and suctioning?

A) Bradycardia
B) Hypertension
C) Hypotension
D) Tachycardia

Explanation: A common complication associated with tracheostomy care and suctioning is bradycardia. Stimulation of the vagus nerve during suctioning can lead to a decrease in heart rate. Nurses should monitor vital signs and intervene promptly if bradycardia occurs.

Correct Answer:

Select an answer A) Bradycardia

 

A 50-year-old patient presents with loud snoring, pauses in breathing during sleep, and excessive daytime sleepiness. Based on these symptoms, what type of sleep apnea is most likely affecting the patient?

A) Obstructive Sleep Apnea (OSA)
B) Central Sleep Apnea (CSA)
C) Mixed Sleep Apnea
D) Complex Sleep Apnea Syndrome

Explanation: The patient’s symptoms, including loud snoring, pauses in breathing during sleep, and excessive daytime sleepiness, are characteristic of Obstructive Sleep Apnea (OSA), which is the most likely diagnosis in this case.

Correct Answer:

Select an answer A) Obstructive Sleep Apnea (OSA)

Which of the following is a common risk factor associated with the development of Obstructive Sleep Apnea (OSA)?

A) Excessive daytime caffeine intake
B) Low body mass index (BMI)
C) Smoking tobacco
D) Regular physical exercise

Explanation: Smoking tobacco is a common risk factor associated with the development of Obstructive Sleep Apnea (OSA). Smoking can lead to airway inflammation and increased upper airway resistance, contributing to OSA.

Correct Answer:

Select an answer C) Smoking tobacco

A patient with suspected sleep apnea undergoes a polysomnography test. What is the primary purpose of this test in diagnosing sleep apnea?

A) To measure daytime sleepiness
B) To assess oxygen saturation during sleep
C) To evaluate the patient’s response to medication
D) To record physiological parameters during sleep

Explanation: The primary purpose of a polysomnography test is to record physiological parameters during sleep. This includes monitoring brain activity, eye movement, heart rate, muscle activity, and oxygen saturation, all of which help diagnose sleep apnea and assess its severity.

Correct Answer:

Select an answer D) To record physiological parameters during sleep

Which of the following interventions is commonly used as a treatment option for Obstructive Sleep Apnea (OSA)?

A) Antidepressant medication
B) Weight loss and lifestyle modification
C) High-dose opioids
D) Smoking cessation therapy

Explanation: Weight loss and lifestyle modification are commonly used as treatment options for Obstructive Sleep Apnea (OSA). These interventions can help reduce excess weight and improve airway function, alleviating symptoms of OSA.

Correct Answer:

Select an answer B) Weight loss and lifestyle modification

A patient with Obstructive Sleep Apnea (OSA) is prescribed continuous positive airway pressure (CPAP) therapy. What is the primary goal of CPAP therapy in managing OSA?

A) To improve memory and cognition
B) To promote weight loss
C) To prevent daytime fatigue and excessive sleepiness
D) To maintain an open airway during sleep

Explanation: The primary goal of continuous positive airway pressure (CPAP) therapy in managing Obstructive Sleep Apnea (OSA) is to maintain an open airway during sleep. CPAP delivers a constant stream of air pressure, preventing airway collapse and improving oxygenation.

Correct Answer:

Select an answer D) To maintain an open airway during sleep

A 65-year-old patient has undergone abdominal surgery and is at risk of postoperative atelectasis. Which nursing intervention should be prioritized to prevent atelectasis and improve lung function?

A) Administering pain medication
B) Encouraging deep breathing exercises
C) Implementing fall precautions
D) Increasing fluid intake

Explanation: To prevent atelectasis and improve lung function in a postoperative patient, encouraging deep breathing exercises is a priority nursing intervention. Deep breathing exercises, along with the use of incentive spirometry, help expand the lungs and maintain proper oxygenation.

Correct Answer:

Select an answer B) Encouraging deep breathing exercises

A patient with a history of falls and a risk of fall-related injuries is admitted to the medical-surgical unit. What fall precautions should the nurse implement for this patient?

A) Administering sedative medications
B) Encouraging frequent ambulation
C) Placing the patient in a room with dim lighting
D) Providing assistance with toileting

Explanation: To implement fall precautions for a patient at risk of fall-related injuries, the nurse should encourage frequent ambulation, provide assistance with toileting as needed, and ensure proper lighting in the patient’s room. Administering sedative medications is contraindicated in fall prevention.

Correct Answer:

Select an answer B) Encouraging frequent ambulation

Incentive spirometry is commonly used to prevent atelectasis and improve lung function. How does the use of incentive spirometry benefit patients?

A) Promotes relaxation and sleep
B) Increases fluid intake
C) Enhances deep breathing and lung expansion
D) Reduces pain and discomfort

Explanation: Incentive spirometry enhances deep breathing and lung expansion. It encourages patients to take slow, deep breaths, which helps prevent atelectasis, increase oxygenation, and improve overall lung function.

Correct Answer:

Select an answer C) Enhances deep breathing and lung expansion

A patient is using incentive spirometry postoperatively. How often should the nurse instruct the patient to perform incentive spirometry exercises?

A) Every 4 hours
B) Once a day
C) Only when experiencing shortness of breath
D) As needed, but at least 10 times a day

Explanation: The nurse should instruct the patient to perform incentive spirometry exercises at least 10 times a day postoperatively to prevent atelectasis and maintain optimal lung function. These exercises should be done consistently throughout the day.

Correct Answer:

Select an answer D) As needed, but at least 10 times a day

Which of the following patients is at the highest risk for developing atelectasis, making the use of incentive spirometry essential?

A) A young adult without any comorbidities
B) An elderly patient with a history of frequent ambulation
C) A patient with a recent abdominal surgery and limited mobility
D) A patient with a history of smoking cessation

Explanation: A patient with a recent abdominal surgery and limited mobility is at the highest risk for developing atelectasis. The decreased mobility and restricted breathing postoperatively increase the risk, making the use of incentive spirometry essential for lung expansion and prevention.

Correct Answer:

Select an answer C) A patient with a recent abdominal surgery and limited mobility

A 72-year-old patient is being discharged after a hospitalization for heart failure exacerbation. The patient lives alone and has difficulty managing medications. What should the nurse prioritize during discharge planning to ensure the patient’s safety and adherence to medication regimens?

A) Provide the patient with written instructions
B) Arrange for home health care services
C) Recommend moving to a long-term care facility
D) Offer a referral to a physical therapist

Explanation: To ensure the safety and medication adherence of a patient with difficulty managing medications and living alone, the nurse should prioritize arranging for home health care services. Home health nurses can assist with medication management and provide necessary care.

Correct Answer:

Select an answer B) Arrange for home health care services

A 45-year-old patient is being discharged after abdominal surgery. The patient has a prescription for pain medication and has a history of substance use disorder. What should the nurse include in the discharge plan to address the patient’s pain management needs while minimizing the risk of substance misuse?

A) Provide a higher dose of pain medication
B) Offer non-pharmacological pain management options
C) Encourage the patient to seek illicit substances
D) Refer the patient to a pain management clinic

Explanation: To address the pain management needs of a patient with a history of substance use disorder, the nurse should prioritize offering non-pharmacological pain management options, such as physical therapy, relaxation techniques, and heat therapy, to minimize the risk of substance misuse.

Correct Answer:

Select an answer B) Offer non-pharmacological pain management options

A 60-year-old patient is being discharged after a hip replacement surgery. The patient’s home has multiple stairs and narrow doorways. What aspect of discharge planning should the nurse address to ensure a safe transition home for this patient?

A) Provide detailed dietary instructions
B) Offer a list of local restaurants
C) Arrange for a home safety assessment
D) Schedule a follow-up appointment with a dentist

Explanation: To ensure a safe transition home for a patient with a home environment that may pose challenges, such as stairs and narrow doorways, the nurse should prioritize arranging for a home safety assessment. This assessment can identify potential hazards and modifications needed for the patient’s safety.

Correct Answer:

Select an answer C) Arrange for a home safety assessment

A 30-year-old patient with diabetes is being discharged after an episode of diabetic ketoacidosis (DKA). The patient’s home does not have a refrigerator. What should the nurse include in the discharge plan to address the patient’s insulin storage needs?

A) Instruct the patient to keep insulin in a warm place
B) Provide a small portable refrigerator
C) Recommend using insulin injections only
D) Suggest frequent pharmacy visits for insulin pickup

Explanation: To address the patient’s insulin storage needs when a refrigerator is not available, the nurse should prioritize providing a small portable refrigerator. This ensures proper insulin storage and helps maintain its effectiveness.

Correct Answer:

Select an answer B) Provide a small portable refrigerator

An 80-year-old patient with heart failure is being discharged. The patient lives with a caregiver who assists with daily activities. What aspect of discharge planning should the nurse prioritize to support both the patient and the caregiver in managing the patient’s care at home?

A) Provide a list of community support groups
B) Recommend respite care services
C) Suggest discontinuing medication
D) Offer a gym membership for the caregiver

Explanation: To support both the patient and the caregiver in managing care at home, the nurse should prioritize recommending respite care services. Respite care provides temporary relief to caregivers, allowing them to rest and recharge while ensuring the patient’s well-being.

Correct Answer:

Select an answer B) Recommend respite care services

A 55-year-old patient with a history of myasthenia gravis is admitted to the hospital with worsening weakness and difficulty swallowing. Which nursing intervention is a priority for this patient to prevent respiratory complications?

A) Administering high-dose corticosteroids
B) Assisting with oral feedings
C) Placing the patient in a supine position
D) Initiating non-invasive positive pressure ventilation (NIPPV)

Explanation: For a patient with myasthenia gravis experiencing worsening weakness and difficulty swallowing, the priority nursing intervention is to initiate non-invasive positive pressure ventilation (NIPPV) to support respiratory function and prevent respiratory complications.

Correct Answer:

Select an answer D) Initiating non-invasive positive pressure ventilation (NIPPV)

A 40-year-old patient with amyotrophic lateral sclerosis (ALS) is experiencing muscle weakness and difficulty with mobility. What assistive device should the nurse recommend to improve the patient’s independence in activities of daily living (ADLs)?

A) Walker
B) Crutches
C) Manual wheelchair
D) Powered mobility scooter

Explanation: To improve the independence of a patient with ALS in activities of daily living, the nurse should recommend a powered mobility scooter. This device allows the patient to move around with ease despite muscle weakness.

Correct Answer:

Select an answer D) Powered mobility scooter

A 30-year-old patient with multiple sclerosis (MS) is experiencing muscle spasms and spasticity. Which medication is commonly prescribed to manage these symptoms in patients with MS?

A) Antidepressants
B) Antibiotics
C) Anti-seizure medications
D) Muscle relaxants

Explanation: Muscle spasms and spasticity in patients with multiple sclerosis (MS) are commonly managed with muscle relaxant medications. These medications help reduce muscle tone and improve comfort.

Correct Answer:

Select an answer D) Muscle relaxants

50-year-old patient with Guillain-Barré syndrome (GBS) is at risk for respiratory compromise. What nursing intervention is essential to monitor and manage respiratory function in this patient?

A) Administering antibiotics
B) Monitoring blood pressure
C) Assessing bowel sounds
D) Continuous monitoring of vital capacity and forced vital capacity

Explanation: For a patient with Guillain-Barré syndrome (GBS) at risk for respiratory compromise, continuous monitoring of vital capacity and forced vital capacity is essential to assess and manage respiratory function. Declining respiratory capacity may require ventilatory support.

Correct Answer:

Select an answer D) Continuous monitoring of vital capacity and forced vital capacity

A 65-year-old patient with Parkinson’s disease is experiencing “off” episodes, characterized by decreased mobility and rigidity. What medication should the nurse recommend to help manage these “off” episodes effectively?

A) Anticoagulants
B) Antacids
C) Levodopa-carbidopa
D) Antihistamines

Explanation: To manage “off” episodes in patients with Parkinson’s disease effectively, the nurse should recommend levodopa-carbidopa, which is a commonly prescribed medication to improve mobility and reduce rigidity in these episodes.

Correct Answer:

Select an answer C) Levodopa-carbidopa

A 38-year-old patient with myasthenia gravis reports difficulty with chewing and swallowing. What dietary modification should the nurse recommend to accommodate this patient’s needs and ensure adequate nutrition?

A) Increase spicy foods in the diet
B) Include hard candies as snacks
C) Offer soft, easy-to-swallow foods
D) Encourage a high-fiber diet

Explanation: To accommodate the needs of a patient with myasthenia gravis who experiences difficulty with chewing and swallowing, it is important to recommend soft, easy-to-swallow foods to ensure adequate nutrition and prevent choking.

Correct Answer:

Select an answer C) Offer soft, easy-to-swallow foods

A 25-year-old patient with muscular dystrophy has difficulty with mobility and frequently uses a wheelchair. What should the nurse include in the plan of care to prevent pressure ulcers in this patient?

A) Limit turning and repositioning
B) Apply pressure-relieving cushions
C) Encourage prolonged sitting
D) Use restrictive seatbelts

Explanation: To prevent pressure ulcers in a patient with muscular dystrophy who uses a wheelchair, the nurse should include the use of pressure-relieving cushions in the plan of care. Regular turning and repositioning are also essential.

Correct Answer:

Select an answer B) Apply pressure-relieving cushions

A 68-year-old patient presents to the emergency department with sudden weakness on one side of the body, slurred speech, and facial drooping. The nurse suspects a stroke. What intervention should be prioritized for this patient?

A) Administer a pain reliever
B) Provide a high-protein diet
C) Perform a neurological assessment
D) Start anticoagulant therapy

Explanation: For a patient presenting with signs of a stroke, the priority intervention is to perform a neurological assessment to determine the type of stroke (ischemic or hemorrhagic) and initiate appropriate treatment. Time is critical in stroke management.

Correct Answer:

Select an answer C) Perform a neurological assessment

A 58-year-old patient has a history of TIAs (Transient Ischemic Attacks). What should the nurse educate the patient about regarding the significance of TIAs?

A) TIAs are minor events with no long-term consequences
B) TIAs are unrelated to the risk of a full stroke
C) TIAs serve as warning signs of an impending stroke
D) TIAs can be treated with over-the-counter pain medication

Explanation: The nurse should educate the patient that TIAs are warning signs of an impending stroke and should not be ignored. They indicate an increased risk of a full-blown stroke and require medical evaluation and preventive measures.

Correct Answer:

Select an answer C) TIAs serve as warning signs of an impending stroke

A 75-year-old patient is prescribed aspirin therapy for secondary stroke prevention. What important information should the nurse include in the patient’s education about taking aspirin?

A) Take aspirin with a glass of grapefruit juice
B) Discontinue aspirin if experiencing mild headache
C) Report any signs of bleeding or black, tarry stools
D) Crush the aspirin tablet for faster absorption

Explanation: The nurse should educate the patient to report any signs of bleeding or black, tarry stools, as aspirin can increase the risk of gastrointestinal bleeding. This information is crucial for monitoring and safety.

Correct Answer:

Select an answer C) Report any signs of bleeding or black, tarry stools

A 60-year-old patient is being discharged after a TIA. What self-care instructions should the nurse provide to this patient to reduce the risk of future TIAs?

A) Limit physical activity to avoid exertion
B) Maintain a high-sodium diet
C) Stop all medications immediately
D) Adhere to prescribed antiplatelet therapy and lifestyle modifications

Explanation: The nurse should instruct the patient to adhere to prescribed antiplatelet therapy and lifestyle modifications, such as dietary changes and exercise, to reduce the risk of future TIAs and stroke.

Correct Answer:

Select an answer D) Adhere to prescribed antiplatelet therapy and lifestyle modifications

A 70-year-old patient has been diagnosed with a hemorrhagic stroke. What is the nurse’s priority intervention for this patient?

A) Administer tissue plasminogen activator (tPA)
B) Monitor and manage blood pressure
C) Provide anticoagulant therapy
D) Administer aspirin immediately

Explanation: The nurse’s priority intervention for a patient with a hemorrhagic stroke is to monitor and manage blood pressure to prevent further bleeding. Administering tPA or anticoagulants would be contraindicated in this case.

Correct Answer:

Select an answer B) Monitor and manage blood pressure

A 68-year-old patient with a history of TIA presents to the emergency department with sudden weakness on one side of the body, slurred speech, and facial drooping. The patient is within the time window for thrombolytic therapy. What is the priority treatment for this patient?

A) Administer anticoagulant therapy
B) Provide oxygen therapy
C) Initiate thrombolytic therapy
D) Apply a cold compress to the affected side

Explanation: The priority treatment for this patient is to initiate thrombolytic therapy (e.g., tissue plasminogen activator or tPA) within the time window to dissolve the clot causing the stroke and improve outcomes.

Correct Answer:

Select an answer C) Initiate thrombolytic therapy

A 62-year-old patient is admitted with an ischemic stroke. What medication is commonly administered to prevent further thrombotic events in this patient?

A) Warfarin (Coumadin)
B) Clopidogrel (Plavix)
C) Heparin
D) Insulin

Explanation: Clopidogrel (Plavix) is commonly administered to patients with ischemic strokes to prevent further thrombotic events by inhibiting platelet aggregation.

Correct Answer:

Select an answer B) Clopidogrel (Plavix)

A 70-year-old patient has been diagnosed with a TIA (Transient Ischemic Attack). What medication is commonly prescribed for secondary prevention to reduce the risk of a full-blown stroke?

A) Aspirin
B) Insulin
C) Muscle relaxants
D) Antibiotics

Explanation: Aspirin is commonly prescribed for secondary prevention in patients with TIAs. It helps reduce the risk of a full-blown stroke by preventing platelet aggregation and blood clot formation.

Correct Answer:

Select an answer A) Aspirin

A 58-year-old patient has been admitted following a hemorrhagic stroke. What is a crucial nursing intervention to manage increased intracranial pressure (ICP) in this patient?

A) Administer anticoagulant therapy
B) Maintain a high-sodium diet
C) Elevate the head of the bed
D) Encourage straining during bowel movements

Explanation: To manage increased intracranial pressure (ICP) in a patient with a hemorrhagic stroke, elevating the head of the bed and maintaining proper head positioning is crucial to promote venous drainage and reduce ICP.

Correct Answer:

Select an answer C) Elevate the head of the bed

A 65-year-old patient is recovering from an ischemic stroke. In addition to medical treatment, what is an essential aspect of stroke rehabilitation and prevention of complications?

A) Avoiding physical therapy
B) Encouraging immobility
C) Early mobilization and physical therapy
D) Administering sedatives

Explanation: Early mobilization and physical therapy are essential aspects of stroke rehabilitation to improve functional outcomes and prevent complications, including contractures and venous thromboembolism.

Correct Answer:

Select an answer C) Early mobilization and physical therapy

A 25-year-old male patient is brought to the emergency department after a motorcycle accident. He is unconscious with no motor function below the chest and absent sensation in the lower extremities. Based on the assessment findings, the nurse suspects a spinal cord injury at which level?

A) Cervical
B) Thoracic
C) Lumbar
D) Sacral

Explanation: The absence of motor function below the chest and absent sensation in the lower extremities indicates a spinal cord injury at the thoracic level, typically T1 to T12.

Correct Answer:

Select an answer B) Thoracic

A 30-year-old female patient with a spinal cord injury reports a sudden severe headache, blurred vision, and difficulty in speaking. What should the nurse suspect and prioritize in the assessment?

A) Autonomic dysreflexia
B) Spinal shock
C) Neurogenic shock
D) Migraine headache

Explanation: The sudden severe headache, blurred vision, and difficulty in speaking may indicate autonomic dysreflexia, a potentially life-threatening condition in patients with spinal cord injuries. Immediate assessment and intervention are crucial.

Correct Answer:

Select an answer A) Autonomic dysreflexia

A 45-year-old patient with a cervical spinal cord injury is experiencing difficulty breathing and has decreased tidal volume. What is the priority intervention by the nurse in this situation?

A) Administer pain medication
B) Apply a cold compress
C) Initiate mechanical ventilation
D) Administer an anticoagulant

Explanation: The priority intervention for a patient with difficulty breathing and decreased tidal volume in a cervical spinal cord injury is to initiate mechanical ventilation to support respiratory function.

Correct Answer:

Select an answer C) Initiate mechanical ventilation

A 35-year-old patient with a thoracic spinal cord injury has lost motor function and sensation below the waist. What term describes this type of spinal cord injury?

A) Paraplegia
B) Quadriplegia
C) Hemiplegia
D) Diplegia

Explanation: A spinal cord injury resulting in the loss of motor function and sensation below the waist is termed “paraplegia,” as it affects the lower extremities.

Correct Answer:

Select an answer A) Paraplegia

A 28-year-old patient with a spinal cord injury is at risk of developing pressure ulcers. What is the primary nursing intervention to prevent pressure ulcers in this patient?

A) Administer antibiotics
B) Apply hot packs
C) Provide frequent position changes
D) Administer anticoagulants

Explanation: The primary nursing intervention to prevent pressure ulcers in a patient with a spinal cord injury is to provide frequent position changes to relieve pressure on vulnerable areas of the skin.

Correct Answer:

Select an answer C) Provide frequent position changes

A 35-year-old male patient sustained a spinal cord injury at the cervical level and presents with paralysis of all four limbs (quadriplegia). What is the primary goal of nursing care for this patient during the acute phase of spinal cord injury management?

A) Administer antibiotics
B) Maintain bowel and bladder function
C) Provide emotional support
D) Prevent further neurological injury

Explanation: The primary goal of nursing care during the acute phase of spinal cord injury management is to prevent further neurological injury by immobilizing the spine and maintaining spinal cord perfusion.

Correct Answer:

Select an answer D) Prevent further neurological injury

28-year-old patient with a thoracic spinal cord injury (paraplegia) is at risk of developing respiratory complications. Which nursing intervention is essential to prevent these complications?

A) Administer anticoagulants
B) Provide frequent skin assessments
C) Encourage ambulation
D) Promote deep breathing and coughing exercises

Explanation: To prevent respiratory complications in a patient with a thoracic spinal cord injury, it is essential to promote deep breathing and coughing exercises to maintain lung function.

Correct Answer:

Select an answer D) Promote deep breathing and coughing exercises

A 40-year-old patient with a lumbar spinal cord injury (paraplegia) is at risk of developing autonomic dysreflexia. Which nursing intervention should be prioritized to prevent this complication?

A) Administer laxatives
B) Maintain a high-sodium diet
C) Elevate the head of the bed
D) Regularly assess for bladder distention

Explanation: To prevent autonomic dysreflexia in a patient with a lumbar spinal cord injury, regular assessment for bladder distention and prompt intervention is essential.

Correct Answer:

Select an answer D) Regularly assess for bladder distention

A 30-year-old patient with a cervical spinal cord injury (quadriplegia) is experiencing chronic neuropathic pain. Which pharmacological intervention is commonly used to manage neuropathic pain in such patients?

A) Nonsteroidal anti-inflammatory drugs (NSAIDs)
B) Opioid analgesics
C) Antibiotics
D) Anticonvulsant medications

Explanation: Anticonvulsant medications are commonly used to manage chronic neuropathic pain in patients with spinal cord injuries.

Correct Answer:

Select an answer D) Anticonvulsant medications

A 50-year-old patient with a spinal cord injury is receiving corticosteroid therapy as part of the treatment plan. What is the primary purpose of corticosteroids in this patient’s management?

A) Pain relief
B) Immune system suppression
C) Blood pressure control
D) Enhancing motor function

Explanation: Corticosteroids are used in spinal cord injury management primarily for their anti-inflammatory effects to reduce spinal cord edema and improve neurological outcomes.

Correct Answer:

Select an answer B) Immune system suppression

A 30-year-old female patient with a history of epilepsy presents to the emergency department after experiencing a tonic-clonic seizure. The nurse’s priority during the postictal phase is to:

A) Administer an antipyretic
B) Administer an anticoagulant
C) Ensure patent airway and oxygenation
D) Prepare for lumbar puncture

Explanation: The priority during the postictal phase is to ensure the patient’s airway is patent and provide oxygenation to prevent hypoxia, which can result from a seizure.

Correct Answer:

Select an answer C) Ensure patent airway and oxygenation

25-year-old male patient with a history of epilepsy is prescribed phenytoin (Dilantin) for seizure control. The nurse educates the patient about the importance of:

A) Taking the medication with grapefruit juice
B) Rapidly discontinuing the medication during pregnancy
C) Regularly monitoring blood levels of the medication
D) Taking the medication only during seizure episodes

Explanation: Phenytoin (Dilantin) requires regular monitoring of blood levels to ensure therapeutic efficacy and prevent toxicity.

Correct Answer:

Select an answer C) Regularly monitoring blood levels of the medication

A 40-year-old patient with epilepsy is prescribed valproic acid (Depakote) for seizure management. The nurse should closely monitor which laboratory parameter while the patient is on this medication?

A) Blood glucose levels
B) Liver function tests
C) Serum potassium levels
D) Hemoglobin levels

Explanation: Valproic acid (Depakote) may affect liver function, so it is crucial to monitor liver function tests while the patient is on this medication.

Correct Answer:

Select an answer B) Liver function tests

A 35-year-old patient with epilepsy has been prescribed lorazepam (Ativan) as a rescue medication for acute seizure episodes. The nurse instructs the patient to use this medication:

A) On a daily basis as a preventive measure
B) At the same time as the daily antiepileptic medication
C) Only when experiencing an acute seizure
D) In combination with alcohol

Explanation: Lorazepam (Ativan) is a rescue medication intended for use during acute seizure episodes, not as a daily preventive measure.

Correct Answer:

Select an answer C) Only when experiencing an acute seizure

A 28-year-old patient with epilepsy is planning to become pregnant. The nurse should educate the patient about the importance of:

A) Discontinuing all antiepileptic medications during pregnancy
B) Using contraception to prevent pregnancy
C) Regularly monitoring serum sodium levels
D) Consulting with a healthcare provider about antiepileptic medication management during pregnancy

Explanation: It is crucial for the patient to consult with a healthcare provider about antiepileptic medication management during pregnancy to ensure the safety of both the mother and the baby.

Correct Answer:

Select an answer D) Consulting with a healthcare provider about antiepileptic medication management during pregnancy

A 25-year-old female patient with a history of epilepsy has been prescribed carbamazepine (Tegretol) for seizure control. The nurse explains to the patient that regular monitoring of which laboratory parameter is essential while on this medication?

A) Blood glucose levels
B) Kidney function tests
C) Serum sodium levels
D) Platelet count

Explanation: Carbamazepine (Tegretol) may lead to hyponatremia, so regular monitoring of serum sodium levels is essential to prevent complications.

Correct Answer:

Select an answer C) Serum sodium levels

A 30-year-old male patient with epilepsy is prescribed phenobarbital for seizure management. The nurse educates the patient about potential side effects, including drowsiness and dizziness. The patient should be advised to:

A) Rapidly discontinue the medication if these side effects occur
B) Avoid all physical activities while taking the medication
C) Drive or operate heavy machinery with caution
D) Stop taking the medication during seizure episodes

Explanation: Patients taking phenobarbital should be advised to use caution when driving or operating heavy machinery due to the potential for drowsiness and dizziness.

Correct Answer:

Select an answer C) Drive or operate heavy machinery with caution

A 35-year-old patient with epilepsy is prescribed levetiracetam (Keppra) as an adjunctive therapy for seizure control. The nurse should inform the patient that this medication may require monitoring of which laboratory parameter?

A) Blood pressure
B) Liver enzymes
C) Serum creatinine levels
D) Red blood cell count

Explanation: Levetiracetam (Keppra) may require monitoring of serum creatinine levels to assess renal function.

Correct Answer:

Select an answer C) Serum creatinine levels

A 28-year-old patient with epilepsy is planning to become pregnant. The nurse should educate the patient about the importance of:

A) Discontinuing all antiepileptic medications during pregnancy
B) Using contraception to prevent pregnancy
C) Regularly monitoring serum sodium levels
D) Consulting with a healthcare provider about antiepileptic medication management during pregnancy

Explanation: It is crucial for the patient to consult with a healthcare provider about antiepileptic medication management during pregnancy to ensure the safety of both the mother and the baby.

Correct Answer:

Select an answer D) Consulting with a healthcare provider about antiepileptic medication management during pregnancy

A 32-year-old patient with epilepsy is prescribed diazepam (Valium) for the management of status epilepticus. The nurse administers the medication intravenously (IV) and monitors the patient closely for which potential adverse effect?

A) Hypertension
B) Bradycardia
C) Respiratory depression
D) Hyperactivity

Explanation: Diazepam (Valium) administered IV can cause respiratory depression, so close monitoring of the patient’s respiratory status is essential.

Correct Answer:

Select an answer C) Respiratory depression

A 45-year-old patient was involved in a motor vehicle accident and sustained a head injury. The nurse assesses the patient for signs of increased intracranial pressure (ICP). Which of the following signs is indicative of increased ICP?

A) Bradycardia
B) Hypertension
C) Dilated and non-reactive pupils
D) Rapid respirations

Explanation: Dilated and non-reactive pupils are a sign of increased intracranial pressure and may indicate a neurological emergency.

Correct Answer:

Select an answer C) Dilated and non-reactive pupils

A 30-year-old patient with a head injury is at risk for cerebral edema. The nurse should closely monitor which parameter to detect early signs of cerebral edema?

A) Blood glucose levels
B) Serum sodium levels
C) Intracranial pressure (ICP)
D) Red blood cell count

Explanation: Monitoring intracranial pressure (ICP) is essential to detect early signs of cerebral edema in patients with head injuries.

Correct Answer:

Select an answer C) Intracranial pressure (ICP)

A 50-year-old patient with a head injury is being monitored for increased intracranial pressure (ICP). The nurse should elevate the head of the patient’s bed to what degree to promote venous drainage and reduce ICP?

A) 15 degrees
B) 30 degrees
C) 45 degrees
D) 60 degrees

Explanation: Elevation of the head of the bed to 30 degrees can help promote venous drainage and reduce intracranial pressure in patients with head injuries.

Correct Answer:

Select an answer B) 30 degrees

A 35-year-old patient with a head injury is at risk for seizures. The nurse should educate the patient and family about the importance of:

A) Administering anticoagulant medications
B) Maintaining strict bed rest
C) Reporting changes in level of consciousness
D) Restricting fluid intake

Explanation: Patients with head injuries are at risk for seizures, so it is essential to educate them and their families about the importance of reporting changes in the level of consciousness.

Correct Answer:

Select an answer C) Reporting changes in level of consciousness

A 40-year-old patient with a head injury is prescribed mannitol to reduce intracranial pressure. The nurse should closely monitor the patient for which potential complication?

A) Hypertension
B) Hypokalemia
C) Fluid overload
D) Hypernatremia

Explanation: Mannitol can lead to fluid overload, so close monitoring of the patient’s fluid status is essential to prevent complications.

Correct Answer:

Select an answer C) Fluid overload

A 32-year-old patient presents to the emergency department with a severe headache, photophobia, and nausea. The patient describes this headache as a pulsating pain on one side of the head, accompanied by visual disturbances. The nurse suspects which type of headache?

A) Tension headache
B) Cluster headache
C) Sinus headache
D) Migraine headache

Explanation: The patient’s symptoms, including photophobia, pulsating pain, and visual disturbances, are indicative of a migraine headache.

Correct Answer:

Select an answer D) Migraine headache

A 45-year-old patient reports experiencing recurrent headaches with a throbbing pain on one side of the head, often preceded by an aura. The nurse recognizes this pattern as characteristic of which type of headache?

A) Cluster headache
B) Sinus headache
C) Tension headache
D) Migraine headache

Explanation: The patient’s description of throbbing pain, aura, and one-sided headaches is consistent with migraine headaches.

Correct Answer:

Select an answer D) Migraine headache

A 28-year-old patient experiences sudden, severe headaches often described as “the worst headache of my life.” The patient also reports neck stiffness and photophobia. The nurse suspects which condition?

A) Migraine headache
B) Tension headache
C) Cluster headache
D) Subarachnoid hemorrhage

Explanation: Sudden, severe headaches with neck stiffness and photophobia are characteristic of a subarachnoid hemorrhage, a medical emergency.

Correct Answer:

Select an answer D) Subarachnoid hemorrhage

A 35-year-old patient complains of recurrent headaches with a sensation of tightness and pressure around the head. The patient states that the pain is usually bilateral and not associated with other symptoms. The nurse suspects which type of headache?

A) Migraine headache
B) Tension headache
C) Cluster headache
D) Sinus headache

Explanation: The patient’s description of bilateral tightness and pressure around the head is consistent with tension headaches.

Correct Answer:

Select an answer B) Tension headache

A 40-year-old patient with a history of migraines asks the nurse about preventive measures. Which non-pharmacological recommendation is appropriate for managing migraine triggers?

A) Avoiding caffeine completely
B) Maintaining a consistent sleep schedule
C) Reducing daily water intake
D) Increasing alcohol consumption

Explanation: Maintaining a consistent sleep schedule is a non-pharmacological approach to managing migraine triggers and promoting overall well-being.

Correct Answer:

Select an answer B) Maintaining a consistent sleep schedule

A 25-year-old patient with a history of migraines experiences an aura before the onset of headache. The nurse should educate the patient about the potential benefits of which migraine-specific medication class for acute attacks?

A) Nonsteroidal anti-inflammatory drugs (NSAIDs)
B) Antidepressants
C) Triptans
D) Antihypertensive agents

Explanation: Triptans are migraine-specific medications that can be effective for treating acute migraine attacks, especially when preceded by an aura.

Correct Answer:

Select an answer C) Triptans

A 30-year-old patient with frequent migraines asks about lifestyle modifications to reduce the frequency and severity of headaches. Which recommendation should the nurse provide?

A) Consume large amounts of caffeine
B) Maintain regular meal patterns
C) Avoid physical activity
D) Limit fluid intake

Explanation: Maintaining regular meal patterns and avoiding skipping meals can help reduce the frequency and severity of migraines.

Correct Answer:

Select an answer B) Maintain regular meal patterns

A 38-year-old patient presents to the clinic with a history of recurrent migraines. The patient is seeking pharmacological options for migraine prevention. Which class of medications is commonly prescribed for migraine prophylaxis?

A) Oral contraceptives
B) Antibiotics
C) Anticoagulants
D) Beta-blockers

Explanation: Beta-blockers are commonly prescribed for migraine prophylaxis due to their ability to reduce the frequency and severity of migraine attacks.

Correct Answer:

Select an answer D) Beta-blockers

A 50-year-old patient has been experiencing chronic daily headaches that are characterized by a constant, dull, and non-pulsatile pain on both sides of the head. The nurse suspects which type of headache in this patient?

A) Migraine headache
B) Tension headache
C) Cluster headache
D) Sinus headache

Explanation: Chronic daily headaches characterized by a constant, dull, and non-pulsatile pain are indicative of tension-type headaches.

Correct Answer:

Select an answer B) Tension headache

HOMEPAGE

NCLEX QBank

A 28-year-old patient presents to the clinic with a history of migraines and is currently pregnant. The patient is seeking recommendations for migraine management during pregnancy. What is an appropriate non-pharmacological approach to managing migraines in pregnant patients?

A) High-dose aspirin therapy
B) Frequent use of over-the-counter pain relievers
C) Maintaining adequate hydration
D) Caffeine intake above 400 mg/day

Explanation: Maintaining adequate hydration and avoiding dehydration can be an important non-pharmacological approach to managing migraines during pregnancy.

Correct Answer:

Select an answer C) Maintaining adequate hydration