NEURO REVIEW PQ

A patient has a history of temporal arteritis and is beginning their steroid taper. How long does the nurse practitioner anticipate the patient has been on steroids?

1 year Rationale: Patients with temporal arteritis are treated with long-term, high-dose steroids that must be tapered down when discontinuing. Due to the highly inflammatory nature of the condition and the high risk of recurrence, patients are typically on steroids for one to two years prior to discontinuing treatment.

How many occurrences of migraines with aura are necessary for an official diagnosis?

2 Rationale: the correct answer is two. For an official diagnosis of migraines with aura, there has to be a history of two occurrences of a migraine, lasting 4-72 hours, with two of the following symptoms: unilateral, pulsating, moderate to severe intensity, and aggravation by or avoidance of activities of daily living. As well, the patient must have one of the following symptoms: nausea, vomiting, photophobia, or phonophobia. The patient must also have a clear description of the aura presentation. For an official diagnosis of migraines without an aura, there has to be a history of five occurrences with the same criteria for symptoms.

The nurse practitioner is initiating sumatriptan (Imitrex) for a 20-year-old female patient for treatment of her migraines. When should the provider instruct the patient to take this medication?

As soon as symptoms begin Rationale: the correct answer is "as soon as symptoms begin." Sumatriptan (Imitrex) is a medication that is used for abortive therapy for migraines, and works best if taken as soon as the person notices the symptoms of a migraine coming on. Abortive therapies should not be taken daily and can be taken for migraines with or without aura. As well, sumatriptan can be taken with or without food.

Which of the following medication classes is the best for prophylactic treatment for cluster headaches?

Calcium channel blockers Rationale: The correct answer is calcium channel blockers. Verapamil (Calan) is the gold standard for prophylaxis for cluster headaches due to its strong characteristics of vasodilation which help to prevent cluster headaches. Beta blockers can be used in the prevention of migraine headaches, ACE-Inhibitors are used for the management of hypertension, and alpha blockers are used in benign prostatic hypertrophy.

A 30-year-old male presents to the clinic reporting a severely painful, unilateral headache. This patient reports that this has happened three times this week, lasts around 2 hours each time, and it feels like a sharp, stabbing pain behind his right eye. The patient is currently having this headache, and upon examination, the nurse practitioner notes that the patient has rhinorrhea and epiphora. Based on this history and physical, what is your primary differential diagnosis for this patient?

Cluster headache Rationale: The correct answer is a cluster headache. Cluster headaches present unilaterally, with sharp, stabbing-like pain behind a patient's eye. It is also stereotypical to see tearing and nasal drainage. Cluster headaches tend to occur in groups, multiple times per week, and are more common in males than females. Temporal arteritis would present unilaterally, but would also have jaw claudication and visual disturbances. Migraines also present unilaterally, but lack tearing and nasal discharge. Tension headaches present bilaterally.

A 57-year-old patient presents with an onset of headache, blurry vision, and jaw pain that started while eating a snack. Which of the following is the most appropriate action by the nurse practitioner?

Initiate prednisone and refer the patient to the emergency room Rationale: This patient is presenting with signs of temporal arteritis (giant cell arteritis). While temporal arteritis is diagnosed via temporal artery biopsy, this patient is reporting vision impairment so treatment with steroids should be initiated immediately and the patient should be referred.

Which of the following conditions is a person at higher risk for when they are diagnosed with atrial fibrillation (A-fib)?

Ischemic stroke Rationale: the correct answer is an ischemic stroke. Atrial fibrillation can increase the potential of blood clots, which can dislodge, block blood vessels, and disrupt blood flow to the brain. Uncontrolled hypertension is associated with hemorrhagic stroke. Risk factors for peripheral arterial disease would be smoking, high blood pressure, and high cholesterol. The incidence of migraine headaches is not increased with atrial fibrillation.

Patients with which condition are at an increased risk of developing temporal arteritis?

Polymyalgia rheumatica Rationale: Temporal arteritis (also referred to as giant cell arteritis) is highly associated with polymyalgia rheumatica. Polymyalgia rheumatica is a highly inflammatory condition affecting the muscles. While the exact cause of both of these conditions is unknown, they are interrelated inflammatory conditions that often affect the same populations and are both treated with corticosteroids.

A 28-year-old male patient states he has had some "pretty intense" headaches recently. He reports that he has had about six of these headaches over the last month and they tend to last about 24 hours at a time. The headaches are usually on the right side and also make him nauseated. What would be the most appropriate treatment option that would help prevent these types of headaches?

Propranolol (Inderal) Rationale: the correct answer is propranolol (Inderal). This patient is experiencing characteristic migraine headaches, and beta blockers such as Propranolol (Inderal) are typically used as prophylaxis. Sumatriptan (Imitrex) and aspirin (Bayer) can be used for migraine treatment, but they are used as abortive therapy. Verapamil (Verelan) can be used for prophylaxis for cluster headaches.

A 50-year-old male patient came into the clinic today concerned about a severe headache. This is a new complaint for him, and he does not have a history of headaches. He says it came out of nowhere and it is the worst headache he ever remembers having. What should the nurse practitioner do next?

Refer to the emergency room Rationale: the correct answer is to refer to the emergency room. This type of headache is known as a "thunderclap headache" and can be a sign of an increased intracranial pressure and a potential hemorrhagic stroke, which requires prompt referral to emergency services. While imaging and a neurology consult would be part of the treatment plan, the patient must be transferred to the emergency room for immediate services. High dose oxygen is used in the treatment of cluster headaches, not a thunderclap headache.

If a cluster headache is not treated appropriately, what is the patient at risk for?

Suicide Rationale: The correct answer is suicide. Due to their intense pain and severe nature, patients may become suicidal if not appropriately managed. Cluster headaches do not predispose patients to chronic migraines, syncope, or cerebrovascular accidents.

A 70-year-old male patient presented to the clinic with left side weakness, drooping of his mouth, slurred speech, and dizziness. The nurse practitioner transferred him to the emergency room with a suspected stroke. Not long after the patient arrived at the emergency room, his symptoms slowly started to improve. Within two hours the patient was feeling his normal self. What is the likely diagnosis?

Transient ischemic attack (TIA) Rationale: the correct answer is a transient ischemic attack (TIA), which can mimic the signs/symptoms of a stroke. However, with a TIA, symptoms resolve on their own without treatment. In the case of a stroke, the symptoms do not resolve without proper treatment. Temporal arteritis presents with jaw pain, a unilateral headache, and potential temporary vision loss.