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 primary hypothyroidism, the thyroid gland is underactive and does not produce sufficient thyroid hormones. As a result, the pituitary gland releases more TSH to stimulate the thyroid, leading to elevated levels of TSH in the blood⁶⁷⁸.
Choice B reason : Free T3 levels might not be elevated in primary hypothyroidism. Free T3 is the active form of triiodothyronine and could be normal or low depending on the severity and type of hypothyroidism⁶.
Choice C reason : Serum T3 levels are typically not the first indicator to change in primary hypothyroidism and may remain within normal ranges even when TSH is elevated⁶.
Choice D reason : Serum T4 levels are expected to be low in primary hypothyroidism because the thyroid gland is not producing enough of this hormone. However, the initial and most sensitive indicator of primary hypothyroidism is an elevated TSH level⁶.
Correct Answer is B
Explanation
Choice A reason : Heat intolerance is not a symptom associated with myxedema coma. Instead, patients with myxedema coma typically present with cold intolerance due to decreased metabolic rate and reduced heat production as a result of hypothyroidism¹.
Choice B reason : Facial edema, particularly around the eyes, is a characteristic finding in myxedema coma. This condition results from severe hypothyroidism, which can cause mucopolysaccharide deposition in the skin, leading to non-pitting edema¹.
Choice C reason : Tachycardia is not expected in myxedema coma; rather, bradycardia is more common due to the reduced metabolic demands of the body in the hypothyroid state¹.
Choice D reason : Diarrhea is not typically a symptom of myxedema coma. Patients are more likely to experience constipation due to slowed gastrointestinal motility in the context of hypothyroidism¹.
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