A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?

"A headache indicates tolerance to the medication.”.

"It sounds as if you are allergic to this medication.”.

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”.

"Your headache is probably a result of anxiety about the chest pain.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.

Choice B rationale:

Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.

Choice C rationale:

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.

Choice D rationale:

Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.

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Correct Answer is C

Explanation

The correct answer is choice C: “I will follow a diet high in calories and protein.”

Here are the rationales for each choice:

Choice A rationale:“I will drink about 34 ounces of fluid every day.” While staying hydrated is important for overall health, this statement does not specifically address a key self-management strategy for emphysema. Adequate fluid intake can help thin mucus, making it easier to expel, but it is not the most critical aspect of managing emphysema.

Choice B rationale:“I will inhale slowly through pursed lips to help me breathe better.” This statement is incorrect because the correct technique is toexhalethrough pursed lips, not inhale. Pursed-lip breathing helps to keep the airways open longer, reduce shortness of breath, and improve the exchange of oxygen and carbon dioxide.

Choice C rationale:“I will follow a diet high in calories and protein.” This is the correct answer. Emphysema can increase the body’s energy expenditure due to the effort required for breathing. A diet high in calories and protein helps maintain muscle mass and provides the necessary energy to support respiratory function.

Choice D rationale:“I will lie on my stomach to practice abdominal breathing every day.” This statement is not recommended for emphysema management. While abdominal or diaphragmatic breathing can be beneficial, lying on the stomach is not a typical position for practicing this technique. It is usually done while sitting or lying on the back.

A. Dull, aching calf pain. B. Positive Kernig's sign. C. Soft, pliable calf muscle. D. Positive Homan's sign. E. None F. None

Correct Answer is A

Explanation

The correct answer is Choice A: Dull, aching calf pain.

Choice A rationale:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.

Choice B rationale:

Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.

Choice C rationale:

Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.

Choice D rationale:

Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.

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A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.The client states that his chest pain is relieved but now he has a headache.Which of the following responses by the nurse is appropriate?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?