A patient with angina is receiving Nitroglycerin and begins to complain of a severe headache. What is the most appropriate response from the nurse?

Headaches can occur due to the vasoconstriction effect of the medication.

I can give you some Morphine to help with that headache.

I will notify the physician immediately.

This is a normal side effect of Nitroglycerin as it dilates your body's vessels.

Answer and Explanation

The Correct Answer is D

Choice A reason: The statement "Headaches can occur due to the vasoconstriction effect of the medication" is incorrect. Nitroglycerin causes vasodilation, not vasoconstriction. Vasodilation increases blood flow, which can lead to headaches as a common side effect.

Choice B reason: Offering Morphine to manage the headache is not the most appropriate initial response. While Morphine can relieve pain, it's essential to educate the patient about the common side effects of Nitroglycerin and provide reassurance. Morphine use should be carefully considered and is typically reserved for more severe pain management.

Choice C reason: Notifying the physician immediately is not necessary in this scenario, as a headache is a known and common side effect of Nitroglycerin. It's more appropriate to educate the patient about the side effects and provide reassurance. Only if the headache is severe and unrelieved by other measures should the physician be notified.

Choice D reason: Explaining that the headache is a normal side effect of Nitroglycerin, which dilates blood vessels, is the most appropriate response. This helps to reassure the patient and provides an understanding of why the headache is occurring. Nitroglycerin works by dilating blood vessels to improve blood flow and reduce angina symptoms, and headaches are a common side effect due to this vasodilation.

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Correct Answer is C

Explanation

Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.

Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.

Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.

Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.

A. Place the client in a side-lying position. B. Administer hydromorphone for pain as prescribed. C. Obtain daily weights. D. Maintain a high-calorie, high-protein diet. E. Monitor the client's respiratory status.

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

Explanation

Choice A reason: Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.

Choice B reason: Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.

Choice C reason: Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.

Choice D reason: Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.

Choice E reason: Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.

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A patient with angina is receiving Nitroglycerin and begins to complain of a severe headache. What is the most appropriate response from the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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

Explanation

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