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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Obsessive-Compulsive Disorder (OCD) is characterized by persistent, unwanted thoughts (obsessions) and behaviors (compulsions) that the individual feels the urge to repeat over and over. While OCD is a separate condition that can co-occur with many disorders, it is not commonly associated as a comorbidity with histrionic personality disorder⁴⁵.

Choice B reason: Schizophrenia is a severe mental disorder that affects how a person thinks, feels, and behaves. It is not typically associated with histrionic personality disorder, which is characterized by excessive emotionality and attention-seeking behaviors⁴⁵.

Choice C reason: Generalized Anxiety Disorder (GAD) is a common comorbidity with histrionic personality disorder. Individuals with histrionic personality disorder may experience high levels of anxiety, which can manifest as GAD. This anxiety often relates to fears of rejection or not being the center of attention⁴⁵.

Choice D reason: Anorexia Nervosa is an eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body weight. It is more commonly associated with other conditions, such as obsessive-compulsive and avoidant personality disorders, rather than histrionic personality disorder⁴⁵.

A. Assure the client that their end-of-life wishes are followed right away. B. Check the medical record for a DNR order. C. Ask the client if they have a healthcare proxy who can speak for them if needed. D. Verify a signed copy of the advance directives in the medical record.

Correct Answer is B

Explanation

Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².

Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².

Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².

Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².

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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?

Nursing Test Bank

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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