A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?
"A headache is an expected side effect of the medication."
"A headache is an indication of an allergy to the medication."
"A headache is likely due to the anxiety about the chest pain."
"A headache indicates tolerance to the medication."
The Correct Answer is A
Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.
Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.
Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.
Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : The symptoms described for the 40-year-old woman align closely with the clinical presentation of a pulmonary embolism. Swelling and pain in the calf may indicate deep vein thrombosis (DVT), which can lead to PE. The presence of chest pain, difficulty breathing, rapid heart rate (tachycardia), and rapid breathing (tachypnea) are hallmark signs of PE³⁴.
Choice B reason : While the 60-year-old man is experiencing fatigue, which can be a symptom of many conditions, there is no direct indication of PE. Acute kidney injury (AKI) after IV antibiotics suggests a different pathophysiology unrelated to PE.
Choice C reason : The 30-year-old man's refusal to ambulate or wear compression stockings after surgery increases his risk for DVT and subsequently PE; however, he does not currently exhibit symptoms that are as indicative of PE as the 40-year-old woman.
Choice D reason : The 55-year-old woman's symptoms could suggest a cardiac event, such as a heart attack, especially with the radiating jaw pain. While PE can present with similar symptoms, the radiating pain is more characteristic of cardiac issues³.
Correct Answer is A
Explanation
Choice A reason : Regular exercise, as tolerated and recommended by a healthcare provider, is beneficial for heart failure patients as it can improve cardiovascular health and overall well-being⁵.
Choice B reason : Taking naproxen sodium for generalized discomfort is not recommended for heart failure patients as nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen heart failure by causing fluid retention and increasing blood pressure⁵.
Choice C reason : Taking diuretics early in the morning is advised to avoid nocturia; however, taking them before bedtime is not recommended for the same reason, as it can disrupt sleep due to the need for frequent urination⁵.
Choice D reason : Patients should be instructed to notify their healthcare provider of a weight gain of 0.5 kg (1 lb) in a week as it may indicate fluid retention, which is a common issue in heart failure⁵.
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