A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, shortness of breath, and nausea.
Which of the following actions should the nurse take?

Choice A rationale

Nitroglycerin causes vasodilation, leading to headaches as a common adverse effect. These headaches are due to the increased blood flow and dilation of cerebral blood vessels.

Choice B rationale

Headaches do not indicate tolerance to nitroglycerin. Tolerance typically presents with a diminished therapeutic effect, not adverse effects like headaches.

Choice C rationale

Anxiety-induced headaches are unlikely since nitroglycerin-induced headaches are a physiological response to vasodilation, not psychological factors.

Choice D rationale

An allergic reaction to nitroglycerin would present with symptoms like rash or itching, not headaches. Headaches are a known and expected adverse effect.

Choice A rationale

Flushed, warm legs are characteristic of chronic venous insufficiency, not peripheral artery disease, which results in poor arterial blood flow and cool extremities.

Choice B rationale

Thin, pliable toenails suggest nutritional deficiencies or fungal infections, not advanced peripheral artery disease, which often leads to thick, brittle nails.

Choice C rationale

Hairy legs are indicative of adequate blood flow. In peripheral artery disease, decreased blood flow results in hair loss on the legs.

Choice D rationale

Leg pain at rest, called rest pain, signifies advanced peripheral artery disease due to severe arterial insufficiency and poor oxygen supply to tissues. .

NGN QUESTIONS