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 D
Explanation
Choice A reason : Nitroglycerin is used to treat angina pectoris and does not typically cause a decrease in potassium levels¹.
Choice B reason : Metoprolol is a beta-blocker used to treat high blood pressure and heart failure but is not known to significantly affect potassium levels¹.
Choice C reason : Spironolactone is a potassium-sparing diuretic and would not contribute to low potassium levels; it is more likely to cause hyperkalemia¹.
Choice D reason : Furosemide is a loop diuretic that can lead to hypokalemia by increasing the excretion of potassium in the urine. It is known to contribute to low potassium levels and should be identified as the medication affecting this lab value¹².
Correct Answer is C
Explanation
Choice A reason : Methadone is an opioid used primarily for opioid maintenance therapy and to relieve severe pain, not typically for alcohol withdrawal. It does not address the specific symptoms associated with alcohol withdrawal such as seizures or delirium tremens¹.
Choice B reason : Salicylates, such as aspirin, are not used to treat alcohol withdrawal. They can increase the risk of bleeding, especially in the gastrointestinal tract, which can be a concern in individuals with a history of heavy alcohol use¹.
Choice C reason : Benzodiazepines, such as chlordiazepoxide, are the first-line treatment for alcohol withdrawal. They help reduce the risk of seizures, ease withdrawal symptoms, and can prevent the progression to more severe forms of withdrawal such as delirium tremens¹².
Choice D reason : Diphenhydramine is an antihistamine with sedative properties, but it is not a first-line medication for alcohol withdrawal. While it may provide some sedation, it does not prevent seizures or other serious complications of alcohol withdrawal¹.
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