A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

"A headache is an indication of an allergy to the medication."

"A headache indicates tolerance to the medication."

"A headache is likely due to the anxiety about the chest pain."

"A headache is an expected adverse eﬀect of the medication."

Answer and Explanation

The Correct Answer is D

A headache is a common and expected adverse eﬀect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.

"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.

"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.

"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.

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Correct Answer is D

Explanation

Using elastic stockings is an eﬀective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.

"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood ﬂow to the legs, worsening the condition.

"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and ﬂuid accumulation in the legs, leading to edema, pain, and skin breakdown

"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.

A. Hold the client's arms and legs from moving. B. Place the client back in bed. C. Place the client on his side. D. Insert a tongue blade in the client's mouth.

Correct Answer is C

Explanation

Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the ﬂoor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.

Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

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A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

Nursing Test Bank

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Correct Answer is D

Explanation

A nurse enters a client's room and finds the client on the ﬂoor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

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