A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

"I will call the provider after taking one dose of nitroglycerin."

"I will hold my breath and bear down."

"I will stop what I am doing and lie down."

"I will take two 325 milligram aspirin tablets at the same time.”

Answer and Explanation

The Correct Answer is C

Choice A: While nitroglycerin is a common medication for angina, calling the provider after just one dose is not the recommended action. Nitroglycerin helps relax coronary arteries and improve blood supply to the heart. However, if chest pain persists, the client should follow additional steps..

Choice B: This describes the Valsalva maneuver, which involves holding the breath and bearing down as though straining to initiate a bowel movement. While this technique can regulate heart rhythms and help the ears to pop, it is not the recommended response to chest pain from angina.

Choice C: Correct: This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.

Choice D: Aspirin can be beneficial during angina episodes. However, the recommended dose is usually 162 to 325 milligrams (one tablet). Taking two tablets at once may not be necessary unless specifically advised by a healthcare provider.

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Correct Answer is B

Explanation

Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.

While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.

The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.

The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.

A. Ask the client if they would like to watch television. B. Use short, simple sentences when speaking with the client. C. Allow the client to have 1 hr of time alone in their room. D. Move the client to a table where other clients are playing cards.

Correct Answer is B

Explanation

By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.

Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.

Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.

Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.

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A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

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