A nurse administered nitroglycerin sublingually to client who has angina pectoris and experienced chest pain. The client states that his chest pain is relieved but now he has a headache. Which of the following responses by the nurse is appropriate?
A headache indicates tolerance to the medication
It sounds as if you are allergic to this medication
Your headache is probably a result of anxiety about the chest pain
A headache is a common adverse effect of this medication, but it will probably occur less often over time
The Correct Answer is D
A) A headache indicates tolerance to the medication:
A headache does not indicate tolerance to nitroglycerin. Tolerance typically refers to the need for increasing doses to achieve the same therapeutic effect, which is more common with medications like nitroglycerin when used chronically.
B) It sounds as if you are allergic to this medication:
While headaches are a common side effect of nitroglycerin, they are not an allergic reaction. Allergies typically cause symptoms such as rash, itching, or swelling, and are not typically associated with nitroglycerin use. Therefore, attributing the headache to an allergy would be inappropriate.
C) Your headache is probably a result of anxiety about the chest pain:
While anxiety can contribute to physical symptoms like headaches, it is not the most likely cause in this case. Nitroglycerin causes vasodilation, which can lead to headaches as a common side effect. Given that the headache occurred shortly after taking the medication, it is much more likely that the headache is a direct result of the nitroglycerin rather than anxiety about the chest pain.
D) A headache is a common adverse effect of this medication, but it will probably occur less often over time:
Headaches are a well-known and common side effect of nitroglycerin due to its vasodilatory effect, which can cause blood vessels in the head to expand, leading to a headache. The nurse's response is appropriate because it reassures the client that the headache is a typical reaction and that it often becomes less frequent with continued use. The nurse should also remind the client to take the medication as prescribed, and if the headache persists or worsens, they should notify their healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) High protein diet:
A high-protein diet is generally not a recommended nonpharmacological treatment for heart failure. While adequate protein intake is important for overall health, heart failure management typically focuses more on regulating sodium, fluid, and caloric intake. In some cases, a high-protein diet could place additional strain on the kidneys or exacerbate other conditions that may complicate heart failure.
B) Limit salt intake:
Limiting salt (sodium) intake is a crucial nonpharmacological strategy in managing heart failure. Excessive sodium can cause the body to retain water, leading to fluid overload, which can worsen heart failure symptoms such as edema, shortness of breath, and elevated blood pressure. Reducing sodium intake helps prevent these complications and aids in controlling symptoms.
C) 50 pound weight loss:
While weight loss may be beneficial for some individuals, especially those who are obese, a sudden or extreme weight loss of 50 pounds is not typically advised for someone with heart failure unless supervised by a healthcare provider. Rapid weight loss can lead to dehydration or electrolyte imbalances, which may exacerbate heart failure symptoms.
D) Decrease Water intake:
While fluid restriction may be necessary for some individuals, especially those with severe fluid retention or in advanced stages of heart failure, it is not a blanket recommendation. The approach to fluid intake should be based on the individual’s condition, including factors such as kidney function and the presence of edema.
Correct Answer is B
Explanation
A) "My heart rate may increase":
Digoxin is primarily used to slow the heart rate, not increase it. One of its actions is to increase the force of contraction of the heart while slowing the conduction through the atrioventricular (AV) node, which typically leads to a decreased heart rate. An increase in heart rate would be an unusual side effect and might indicate digoxin toxicity or another underlying issue.
B) "My vision may get blurred":
A common side effect of digoxin toxicity is visual disturbances, which may include blurred vision, yellow-green halos, or other color vision abnormalities. These symptoms are often associated with elevated digoxin levels in the blood and are a hallmark sign of toxicity.
C) "I may have constipation after taking this medication":
Constipation is not a typical side effect of digoxin. While some medications may cause constipation, this is not a primary or common side effect of digoxin. If constipation occurs, it may be due to other factors, such as diet, other medications, or a comorbid condition.
D) "My abdomen may hurt after taking this medication":
Although abdominal discomfort can be a side effect of many medications, it is not a primary or typical side effect of digoxin. If the patient experiences abdominal pain, it could be related to digoxin toxicity, especially if accompanied by other symptoms like nausea, vomiting, or diarrhea.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.