Practice Question
A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)
Answer Choices:
Correct Answer:
"Have you had any nausea and vomiting with your headache?"
Rationale:
🟩 "Have you had any nausea and vomiting with your headache?"
🟩 Nausea and vomiting are among the most common associated symptoms of migraine due to the activation of the trigeminovascular system and brainstem centers controlling nausea.
🟩 Asking about these symptoms helps the nurse classify whether the headache is consistent with a migraine rather than a tension or sinus headache.
🟩 These symptoms also help determine the severity of the migraine and guide medication choices, since clients with nausea may need non-oral or antiemetic support.
🟩 Presence of nausea often indicates that the migraine is significantly impacting neurologic pathways and may last longer or be more disabling.
🟩 "Are you bothered by the lights in here?"
🟩 Sensitivity to light (photophobia) is a hallmark neurological sign of migraines, caused by heightened sensory processing in the optic pathway.
🟩 Assessing photophobia helps differentiate migraines from other headache types and allows the nurse to adjust the environment to reduce symptom severity.
🟩 Photophobia also indicates that the patient’s migraine involves cortical hypersensitivity, which contributes to the throbbing, pulsating nature of the pain.
🟩 Environmental triggers like bright lights can worsen symptoms, so documenting this sensitivity helps guide future prevention strategies.
🟩 "Have you noticed any confused or cloudy thinking?"
🟩 Cognitive changes such as confusion, slowed thinking, or “brain fog” are recognized symptoms during migraine attacks due to altered cerebral blood flow and neurochemical changes.
🟩 Asking about cognitive effects helps the nurse determine the extent of neurologic involvement during the migraine episode.
🟩 This is especially important to identify more complex migraines, where neurological deficits can mimic stroke-like symptoms.
🟩 Cognitive assessment can also help evaluate safety concerns, such as impaired ability to make decisions, work, or drive during a migraine.
🟩 "Have you experienced or are you experiencing any strange smells?"
🟩 Strange smells such as burning, perfume, or chemicals may indicate an olfactory aura, which occurs before or during some migraines.
🟩 Auras reflect temporary disruptions in cortical function, often involving visual, sensory, or olfactory pathways.
🟩 Identifying aura symptoms helps classify the migraine type and improves treatment planning, especially with medications more effective when taken early.
🟩 Knowing whether auras occur can help anticipate the onset pattern of future migraines and implement early interventions.
❌ Incorrect Option
"Did you feel weak before the headache started?"
Weakness is typically associated with hemiplegic migraines, a rare subtype that is not routinely screened for during standard migraine assessment.
Asking this is not appropriate for general migraine evaluation because weakness is not a typical or expected symptom.
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This question is from Custom: PNSG 1620 Adult Health III Neuro/Sensory Final AUG which contains 55 questions.
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From Exam
Custom: PNSG 1620 Adult Health III Neuro/Sensory Final AUG
55 Questions
View Full Exam Start PracticingQuestion Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Medical-Surgical
- Answer Choices: 5