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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Fever is a common sign of acute pancreatitis and indicates an inflammatory response. Inflammation of the pancreas can trigger the release of cytokines and other inflammatory mediators, leading to an elevated body temperature. This is a common symptom observed in many cases of acute pancreatitis and suggests an ongoing inflammatory process.
Choice B reason: Gray-blue discoloration of the flank or umbilical area, also known as Grey Turner's sign and Cullen's sign respectively, indicates bleeding and severe inflammation within the pancreas. These signs are indicative of retroperitoneal hemorrhage or pancreatic necrosis, which are severe complications of acute pancreatitis. The presence of such discoloration is a significant finding that suggests a more serious form of the condition.
Choice C reason: Hypertension is not typically associated with acute pancreatitis. In fact, patients with acute pancreatitis are more likely to experience hypotension due to fluid shifts, inflammatory responses, and potential hemorrhage. Monitoring blood pressure is important in these patients to manage any potential complications.
Choice D reason: Decreased amylase level is not an expected finding in acute pancreatitis. Typically, acute pancreatitis is associated with elevated levels of pancreatic enzymes such as amylase and lipase due to inflammation and damage to the pancreatic cells, which release these enzymes into the bloodstream.
Choice E reason: Nausea and vomiting are common symptoms in acute pancreatitis. The inflammation of the pancreas and the associated pain can stimulate the vomiting center in the brain and lead to nausea and vomiting. These symptoms are often severe and can significantly affect the patient's comfort and hydration status.
Choice F reason: Severe abdominal pain is one of the hallmark signs of acute pancreatitis. The pain is typically located in the upper abdomen and may radiate to the back. It is often described as constant and severe, and can be exacerbated by eating or lying flat. Effective pain management is a critical aspect of caring for patients with acute pancreatitis.
Correct Answer is B
Explanation
Choice A reason: Inotropic drugs are used to improve the strength of the heart's contractions and support cardiac output in cases of heart failure or cardiogenic shock. While they may be used as supportive therapy in septic shock to maintain blood pressure and perfusion, they are not the primary treatment.
Choice B reason: Antibiotics are the primary and most crucial therapy for managing septic shock. Septic shock is caused by a severe infection that leads to systemic inflammation and organ dysfunction. Prompt administration of broad-spectrum antibiotics is essential to target the underlying infection and prevent the progression of septic shock. Antibiotic therapy is initiated as soon as possible, often after obtaining blood cultures to identify the causative pathogen.
Choice C reason: Antidysrhythmic drugs are used to manage abnormal heart rhythms, such as atrial fibrillation or ventricular tachycardia. They are not specific to the treatment of septic shock but may be used if the patient develops arrhythmias as a complication of the shock state.
Choice D reason: Beta blockers are used to manage hypertension and certain types of arrhythmias by reducing the heart rate and the workload on the heart. They are not typically used in the acute management of septic shock and may even be contraindicated due to their potential to decrease cardiac output.
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