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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should place a towel under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
Place the client in a prone position is wrong because it can compromise the client's breathing and increase the risk of aspiration. The nurse should place the client in a side-lying position after the seizure to facilitate drainage of oral secretions and prevent aspiration.
Holding the client's arms and legs still is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure but rather ensure a safe environment and observe the seizure activity.
Leaving the client to get help is wrong because it can endanger the client's safety and well-being. The nurse should stay with the client during the seizure and call for assistance if needed, but not leave the client alone or unattended.

Correct Answer is A
Explanation
Aphasia is a language disorder that affects the ability to understand or produce speech. It can be caused by damage to the brain regions that control language, such as from a stroke. Depending on the type and severity of aphasia, the client may have difficulty with comprehension, expression, reading, or writing. Communication strategies for clients with aphasia include using nonverbal cues, such as gestures, facial expressions, pictures, or objects, to supplement verbal messages and enhance understanding.
The other options are not correct because:
a. "Use simple, childlike statements when speaking." This statement is incorrect because it is patronizing and disrespectful to the client. The client's cognitive and intellectual abilities are not affected by aphasia, only their language skills. The nurse should use simple and clear sentences, but not childish or demeaning ones.
c. "Use a higher-pitched tone of voice when speaking." This statement is incorrect because it is unnecessary and may be irritating to the client. The client's hearing is not affected by aphasia, only their language processing. The nurse should use a normal tone of voice and speak slowly and clearly.
d. "Ask multiple choice questions as part of the conversation." This statement is incorrect because it may be confusing and frustrating to the client. The client may have difficulty with verbal output or comprehension, and
multiple choice questions may add to their cognitive load. The nurse should ask yes or no questions or use gestures or pictures to elicit responses from the client.
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