The nurse is determining care for a patient with acute migraine headaches. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches?
a. Keep a headache diary.
b. Avoid sugar and caffeine.
c. Avoid bright light and noise.
d. Avoid taking analgesics until the cause has been determined.
ANS: A
The patient can identify aggravating factors by keeping a headache diary for a time, recording the time of day the headache occurs, foods eaten or other aggravating factors, description of the pain, identification of associated symptoms such as nausea or visual disturbances, and other factors related to headache symptoms. B. C. Avoiding foods or lights and noise might be helpful, but they do not help identify factors causing headaches. D. Avoiding analgesics is unrealistic.
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When calling the primary health care provider regarding a woman's admission, the perinatal nurse includes this information:
A) Gestational age and estimated date of birth B) Status of the membranes C) Patient's vital signs D) Presence of support person(s)
A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8 hours. Which of the following should the nurse do to assist this client?
1. This is a normal urine output, and the nurse does not need to do anything in addition to help the client. 2. Notify the physician since the client could be dehydrated 3. Assist the client to ambulate 4. Measure abdominal girth as a true assessment of the client's fluid status
A patient receiving aminophylline (Theophylline) by continuous IV infusion for a severe asthma attack asks why a blood sample must be drawn. What is the nurse's best response?
a. "The blood level of this drug that causes dangerous side effects is close to the level needed to help open the airways." b. "The blood test helps us evaluate how well the drug is working to open your air-ways and improve your oxygen intake." c. "The blood test helps determine how much of this drug you are making naturally and how much we are giving you." d. This blood tests assesses whether you are developing an allergy to this drug."
You have been working with a client whose wife was killed by a burglar who broke into their home while the client was out of town on a business trip
The client comes to his session today and asks about places where he can donate his wife's clothes and belongings "when I'm ready to give them up." You correctly view this statement as an indication that the client is most likely: a. preparing to commit suicide in order to rejoin his deceased wife b. entering the impoverishment phase as symbolized by the giving away of possessions c. stuck in the maladaptive equilibrium phase shown by his need to get rid of her things d. beginning to shift from the present- to future-directed thinking