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 A
Explanation
Choice A reason : In end-stage kidney disease, the kidneys are unable to excrete excess fluid, leading to fluid overload or hypervolemia. This condition can manifest as shortness of breath due to pulmonary edema, swelling in the lower extremities, and crackles in the lungs upon auscultation. Elevated blood pressure is also a common finding in hypervolemia due to the increased volume of fluid in the bloodstream⁵⁶⁷⁸.
Choice B reason : Hypovolemia, or decreased blood volume, is not consistent with the symptoms described. It typically presents with signs of dehydration, low blood pressure, and tachycardia, which are not mentioned in the client's manifestations.
Choice C reason : Hyponatremia, or low sodium levels in the blood, can occur in ESKD due to dilution from retained fluids, but the primary symptoms described by the client are more indicative of fluid overload rather than electrolyte imbalance alone.
Choice D reason : Hyperkalemia, or high potassium levels, is a serious complication of ESKD due to the kidneys' inability to excrete potassium. While it is a concern in ESKD, the symptoms described by the client are more directly related to fluid overload.
Correct Answer is D
Explanation
Choice A reason : Abdominal distension is more commonly associated with right-sided heart failure due to fluid accumulation in the abdominal cavity. Left-sided heart failure primarily affects the lungs, leading to respiratory symptoms¹.
Choice B reason : Jugular venous distention is typically a sign of right-sided heart failure, indicating increased pressure in the right atrium and venous system. It is not a primary symptom of left-sided heart failure¹.
Choice C reason : Dependent edema, or swelling in the lower extremities, is also more indicative of right-sided heart failure, where fluid accumulates due to poor venous return. In left-sided heart failure, fluid backs up into the lungs rather than the extremities¹.
Choice D reason : A hacking cough, especially when lying down, is a symptom of left-sided heart failure, as fluid backs up into the lungs causing pulmonary congestion. This can lead to coughing and shortness of breath, particularly during exertion or when lying flat¹.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.