A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?
"A headache is an expected side effect of the medication."
"A headache is an indication of an allergy to the medication."
"A headache is likely due to the anxiety about the chest pain."
"A headache indicates tolerance to the medication."
The Correct Answer is A
Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.
Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.
Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.
Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Individuals with this disorder may avoid work activities or decline job offers due to fears of criticism or rejection. However, they do not typically exhibit a need for constant reassurance or an inability to make decisions, which are more indicative of dependent personality disorder⁵⁶.
Choice B reason : Borderline personality disorder involves a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. While individuals with borderline personality disorder may exhibit dependency traits, they are more likely to engage in frantic efforts to avoid real or imagined abandonment and may have a pattern of unstable and intense interpersonal relationships⁷⁸.
Choice C reason : Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. Individuals with this disorder often require excessive advice and reassurance from others to make everyday decisions and may feel helpless when alone due to exaggerated fears of being unable to care for themselves. The need for constant reassurance and inability to make decisions align with the symptoms of dependent personality disorder¹²³⁴.
Choice D reason : Schizoid personality disorder is characterized by a lack of interest in social relationships, a tendency toward a solitary lifestyle, secretiveness, emotional coldness, detachment, and apathy. Individuals with schizoid personality disorder prefer to be alone and do not seek out social interactions or relationships. They do not typically display the need for reassurance or the inability to make decisions, as seen in dependent personality disorder¹²¹³¹⁴.
Correct Answer is A
Explanation
Choice A reason : Individuals with OCD often engage in compulsive behaviors, such as picking up after others, to make their environment feel more controlled or tolerable. This behavior is a response to the anxiety produced by their obsessions, which in this case, could be related to cleanliness or order¹. By controlling their immediate environment, they may feel a temporary relief from their anxiety, even though this relief is often short-lived and the compulsion becomes a repetitive cycle².
Choice B reason : Changing tasks is not typically the goal of compulsive behaviors in OCD. These behaviors are usually very specific and are performed to manage the anxiety associated with particular obsessions. While the individual might switch from one compulsive behavior to another, it is not done with the intention of task variation but rather as a response to shifting obsessive thoughts¹.
Choice C reason : Compulsive behaviors in OCD are not aimed at increasing social interaction. In fact, these behaviors can often interfere with social activities and relationships, as they can be time-consuming and may make the individual feel embarrassed or ashamed, leading to social isolation².
Choice D reason : Compulsive behaviors can sometimes be a way for individuals with OCD to exert control over other behaviors or thoughts. However, the primary function of these behaviors is to manage the anxiety associated with obsessions, not necessarily to control other unrelated behaviors¹.
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