A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

An expected side effect of the medication

An allergic reaction to the nitroglycerin

A sign that the medication should not be used again

An indication of worsening cardiac condition

Answer and Explanation

The Correct Answer is A

Choice A reason: A headache is a common and expected side effect of nitroglycerin. Nitroglycerin causes vasodilation, which can lead to increased blood flow to the head and result in headaches. It is important to inform the client that this is a known side effect and to manage it with appropriate measures, such as taking analgesics.

Choice B reason: An allergic reaction to nitroglycerin would typically present with symptoms such as rash, itching, swelling, or difficulty breathing. A headache alone does not indicate an allergic reaction.

Choice C reason: A headache does not mean the medication should not be used again. It is a common side effect, and the benefits of nitroglycerin in relieving chest pain usually outweigh the discomfort of the headache. The nurse should educate the client on managing the headache while continuing the medication.

Choice D reason: A headache is not an indication of a worsening cardiac condition. It is a common side effect of the vasodilatory effects of nitroglycerin.

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Correct Answer is D

Explanation

Choice A reason: Polyuria, nausea, and headaches are not specific clinical manifestations of thyroid storm. Thyroid storm is characterized by extreme hyperthyroidism, leading to severe symptoms such as high fever and tachycardia. Polyuria and nausea could occur in various conditions but are not hallmark signs of a thyroid storm.

Choice B reason: Polydipsia, translucent skin, and obesity are not typical manifestations of thyroid storm. These symptoms are more associated with other conditions, such as diabetes (polydipsia) and metabolic disorders (obesity). Thyroid storm involves acute and severe symptoms related to excessive thyroid hormone levels.

Choice C reason: Profuse sweating and flushing can occur in thyroid storm, but constipation is not typically observed. In fact, hyperthyroidism generally increases gastrointestinal motility, leading to diarrhea rather than constipation. Thyroid storm involves symptoms reflecting severe metabolic overactivity.

Choice D reason: High fever, severe tachycardia, and hypertension are classic clinical manifestations of thyroid storm. The condition involves a rapid and life-threatening escalation of hyperthyroid symptoms, requiring immediate medical attention to prevent complications.

A. Hyperkalemia. B. Increased glomerular filtration rate (GFR). C. Decreased creatinine level. D. Hypovolemia.

Correct Answer is A

Explanation

Choice A reason: Hyperkalemia is a common finding in the oliguric phase of acute kidney injury due to reduced excretion of potassium by the kidneys. This electrolyte imbalance can have serious cardiac effects and should be expected and monitored in these patients.

Choice B reason: An increased glomerular filtration rate (GFR) would not be expected in the oliguric phase of acute kidney injury. Typically, GFR is decreased due to reduced kidney function during this phase.

Choice C reason: Decreased creatinine levels are not expected in acute kidney injury. Creatinine levels usually increase as kidney function declines and the body cannot adequately filter waste.

Choice D reason: Hypovolemia is not typically expected in the oliguric phase of acute kidney injury, as oliguria (reduced urine output) often indicates fluid retention rather than fluid loss.

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A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the medical ICU suspects that the client is experiencing a thyroid storm. Which clinical manifestations should the nurse anticipate?

Correct Answer is D

Explanation

A nurse in the med-surgical ICU is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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