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 B

Explanation

Choice A reason : Albuterol is a bronchodilator often used in asthma to relieve symptoms of bronchospasm. While it can help open airways, in a case of anaphylaxis, it does not address the systemic histamine release and is not the first-line treatment¹.

Choice B reason : Epinephrine is the primary treatment for anaphylaxis, which is a severe allergic reaction that can occur after a bee sting. It works rapidly to improve breathing, stimulate the heart, reverse hives, and reduce swelling of the face, lips, and throat¹³. In an emergency situation where a patient is experiencing anaphylactic symptoms such as difficulty breathing and a feeling of a lump in the throat, immediate administration of epinephrine is critical to counteract the reaction.

Choice C reason : The term "high-residual cannula" does not correspond to a recognized medical treatment or device. In the context of anaphylaxis, oxygen may be administered via a high-flow nasal cannula if the patient is experiencing respiratory distress, but this would be secondary to the administration of epinephrine.

Choice D reason : The option "Administer 5 mg prescription of the bee" is nonsensical as it does not refer to a legitimate medical treatment. In the context of bee stings, no medication is prescribed as "prescription of the bee."

A. Act as if the hallucination is real. B. Instruct the client to argue with the voices that are part of the hallucination. C. Ask the client direct questions about the hallucination. D. Tell the client that the hallucination is not a part of reality.

Correct Answer is D

Explanation

Choice A reason : Acting as if the hallucination is real can validate the client's false perceptions and potentially reinforce the hallucination. It is important to maintain a sense of reality and not to enter into the client's hallucinatory experience.

Choice B reason : Instructing the client to argue with the voices is not therapeutic. It can increase the client's agitation and anxiety, and it does not help in distinguishing reality from hallucinations.

Choice C reason : While it is important to understand the client's experience, asking direct questions about the hallucination may lead the client to focus more on the hallucination, which can reinforce its presence. The nurse should focus on reality-based topics.

Choice D reason : This is the correct action. The nurse should gently and firmly reassure the client that the hallucination is not real and is a symptom of their illness. This helps to orient the client to reality and can reduce the distress associated with hallucinations.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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