A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
a. Ipsilateral tearing of the eye
b. Miosis
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness
e. Nasal congestion
f.
Exophthalmos
ANS: A, B, E
Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
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What will be an ideal response?
To create a new nutritional plan of care for a patient, the nurse needs to do which of the follow-ing? (Select all that apply.)
a. Utilize the characteristics of a normal nu-tritional status. b. Evaluate previous patient responses to nursing interventions. c. Exclude established expected outcomes to evaluate patient responses. d. Design innovative interventions to meet the patient's needs. e. Follow through with evaluation and counseling.
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