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 B

Explanation

Choice A reason: A sore that appears to be healed is not a common indicator of malignancy. It is usually associated with infections or other skin conditions.

Choice B reason: Changes in a mole's shape and size are classic warning signs of melanoma, a type of skin cancer. Moles that become asymmetrical, have irregular borders, vary in color, grow in diameter, or evolve over time need to be evaluated by a healthcare provider.

Choice C reason: Purulent drainage from a mole could indicate an infection, but it is not a typical sign of malignancy.

Choice D reason: Intense pruritus (itching) can be associated with skin conditions, but it is not a definitive indicator of malignancy. While itching can occasionally be a symptom of skin cancer, it is not as specific as changes in mole appearance.

A. Clear-colored outflow B. Outflow amount exceeds inflow amount C. Cloudy opaque colored outflow D. Non-purulent outflow

Correct Answer is C

Explanation

Choice A reason: Clear-colored outflow is normal and indicates that the dialysis process is functioning correctly.

Choice B reason: Outflow amount exceeding inflow amount may be noted and reported, but it is not an immediate cause for concern unless accompanied by other symptoms.

Choice C reason: Cloudy opaque colored outflow indicates possible peritonitis, an infection of the peritoneum. This is a serious complication that requires immediate medical attention to prevent further complications.

Choice D reason: Non-purulent outflow is not an immediate cause for concern and indicates that there is no infection present.

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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

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Correct Answer is C

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