The client says to the nurse, "I get a headache every time I put on my Nitropatch." Which response by the nurse would be most appropriate?
Avoid strenuous activity and stand up slowly.
Headache is expected and should subside with continued use.
You may reduce your dosage to help relieve this side effect.
You will have this side effect as long as you are taking nitroglycerin.
The Correct Answer is D
Choice A reason: Avoiding strenuous activity and standing up slowly is not a relevant response to the client's complaint of headache. These actions may help prevent or reduce orthostatic hypotension, which is another possible side effect of nitroglycerin, but not headache.
Choice B reason: Headache is expected and should subside with continued use is a correct and appropriate response to the client's complaint of headache. The nurse should explain that headache is a common and transient side effect of nitroglycerin, which is caused by the vasodilation effect of the drug. The nurse should also advise the client to take over-the-counter analgesics, such as acetaminophen, to relieve the headache.
Choice C reason: Reducing the dosage to help relieve this side effect is not a correct or appropriate response to the client's complaint of headache. The nurse should not suggest any changes in the prescribed dosage of nitroglycerin, as this may compromise the effectiveness of the drug and increase the risk of angina or myocardial infarction. The nurse should also remind the client to follow the instructions for applying and removing the Nitropatch.
Choice D reason: You will have this side effect as long as you are taking nitroglycerin is not a correct or appropriate response to the client's complaint of headache. The nurse should not discourage or alarm the client by implying that the headache is inevitable and permanent. The nurse should reassure the client that the headache will likely diminish over time as the body adapts to the drug.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increasing calcium in the diet is not the most important instruction for a client with hypertension. Calcium is a mineral that helps maintain bone health and muscle contraction, but it does not have a significant effect on blood pressure. The nurse should advise the client to limit sodium, fat, and alcohol intake, and to eat more fruits, vegetables, and whole grains.
Choice B reason: Obtaining blood pressure checks twice a year is not the most important instruction for a client with hypertension. This frequency is too low for a client who has a chronic condition that requires close monitoring and treatment. The nurse should advise the client to check their blood pressure regularly, preferably at home, and to report any abnormal readings to their health care provider.
Choice C reason: Monitoring weight on a weekly basis is not the most important instruction for a client with hypertension. Weight is a factor that can influence blood pressure, but it is not the only one. The nurse should advise the client to maintain a healthy weight and to lose weight if they are overweight or obese, but not to focus on the scale alone.
Choice D reason: Getting regular physical activity is the most important instruction for a client with hypertension. Physical activity can lower blood pressure by strengthening the heart, improving blood circulation, reducing stress, and preventing or managing other risk factors, such as obesity, diabetes, and high cholesterol. The nurse should advise the client to engage in moderate aerobic exercise for at least 30 minutes a day, five days a week, and to consult their health care provider before starting any new exercise program.
Correct Answer is D
Explanation
Choice A reason: Taking a baby aspirin with a full glass of cold water at bedtime is not a good discharge instruction for this client. Aspirin can increase the risk of bleeding, especially in the stomach and intestines. ¹ Taking aspirin at bedtime may increase the exposure of the GI mucosa to the drug and worsen the bleeding. ² Cold water may also irritate the stomach lining and cause discomfort.
Choice B reason: Taking 81 mg of enteric coated aspirin with orange juice at lunch time is not a good discharge instruction for this client. Enteric coated aspirin is designed to dissolve in the small intestine, not the stomach, to reduce the risk of GI bleeding. ³ However, orange juice is acidic and may damage the coating and release the aspirin in the stomach. ⁴ This may increase the bleeding and cause pain or ulcers.
Choice C reason: Taking the aspirin with some ginseng tea in the evening is not a good discharge instruction for this client. Ginseng is an herbal supplement that may interact with aspirin and increase the risk of bleeding. ⁵ Taking the aspirin in the evening may also have the same drawbacks as taking it at bedtime, as explained in choice A.
Choice D reason: Taking the aspirin with a glass of milk or food in the morning is the best discharge instruction for this client. Milk and food can help protect the stomach lining from the irritating effects of aspirin and reduce the risk of bleeding. Taking the aspirin in the morning can also minimize the exposure of the GI mucosa to the drug during the night, when the stomach is empty and more vulnerable. ²
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