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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason : Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Individuals with this disorder may avoid work activities or decline job offers due to fears of criticism or rejection. However, they do not typically exhibit a need for constant reassurance or an inability to make decisions, which are more indicative of dependent personality disorder⁵⁶.

Choice B reason : Borderline personality disorder involves a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. While individuals with borderline personality disorder may exhibit dependency traits, they are more likely to engage in frantic efforts to avoid real or imagined abandonment and may have a pattern of unstable and intense interpersonal relationships⁷⁸.

Choice C reason : Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. Individuals with this disorder often require excessive advice and reassurance from others to make everyday decisions and may feel helpless when alone due to exaggerated fears of being unable to care for themselves. The need for constant reassurance and inability to make decisions align with the symptoms of dependent personality disorder¹²³⁴.

Choice D reason : Schizoid personality disorder is characterized by a lack of interest in social relationships, a tendency toward a solitary lifestyle, secretiveness, emotional coldness, detachment, and apathy. Individuals with schizoid personality disorder prefer to be alone and do not seek out social interactions or relationships. They do not typically display the need for reassurance or the inability to make decisions, as seen in dependent personality disorder¹²¹³¹⁴.

A. Nagging cough B. Nonhealing sore C. Change in moles D. Bloating E. Change in bowel pattern

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason : A nagging cough can be a warning sign of cancer, particularly lung cancer. If a cough persists for weeks or longer, especially if it's accompanied by blood or sputum, it should be evaluated by a healthcare professional. Persistent coughing can also be symptomatic of laryngeal or thyroid cancer¹.

Choice B reason : A nonhealing sore that persists for more than a few weeks can be a sign of skin cancer, including melanoma, basal cell carcinoma, or squamous cell carcinoma. It's also a common sign of oral cancer, especially in individuals who use tobacco or consume excessive alcohol¹.

Choice C reason : A change in moles or other skin lesions can be an early indication of skin cancer. The ABCDE rule is a guide to the usual signs of melanoma, looking for Asymmetry, Border irregularity, Color changes, Diameter greater than 6mm, and Evolving size, shape or color².

Choice D reason : While bloating can be caused by many benign conditions, persistent bloating that doesn't go away can be a sign of ovarian or other types of abdominal cancers. It's important to consider this symptom in conjunction with other signs and symptoms¹.

Choice E reason : A change in bowel pattern, such as persistent diarrhea or constipation, can indicate colorectal cancer. Any significant changes in bowel habits that do not resolve over time warrant medical evaluation¹.

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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?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","E"]

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