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 B

Explanation

Choice A reason : Fibromyalgia can indeed be associated with migraine headaches. Many individuals with fibromyalgia report experiencing headaches, and migraines are a common comorbidity. The exact link between fibromyalgia and migraines is not fully understood, but it is believed that the same abnormalities in neurotransmitter levels that contribute to fibromyalgia pain may also predispose individuals to migraines¹².

Choice B reason : The statement "Fibromyalgia causes joint inflammation" is incorrect and indicates a need for further teaching. Fibromyalgia does not cause inflammation within the joints. It is characterized by widespread musculoskeletal pain, fatigue, and tenderness in specific areas, but it does not involve the type of joint inflammation seen in conditions like rheumatoid arthritis¹². This misconception may arise because the symptoms can be similar to those of arthritic conditions, but the underlying mechanisms are different.

Choice C reason : Fibromyalgia may indeed cause chest pain, which is often referred to as costochondritis when it involves the cartilage of the rib cage. This chest pain can mimic that of a heart attack or other heart conditions, but it is actually a common symptom of fibromyalgia and is related to the tender points in the chest area¹².

Choice D reason : It is true that fibromyalgia symptoms may worsen depending on the weather. Many patients report that their symptoms flare up in response to changes in weather, temperature, and humidity. However, the reasons for this sensitivity are not entirely clear, and research on the subject has produced mixed results¹².

A. Tongue thrusting and lip smacking B. Fine hand tremors and pill rolling C. Urinary retention and constipation D. Loud talking and pacing

Correct Answer is A

Explanation

Choice A reason : Tongue thrusting and lip smacking are classic signs of tardive dyskinesia (TD), a side effect of long-term use of dopamine receptor-blocking agents like haloperidol¹. TD is characterized by repetitive, involuntary, purposeless movements, primarily affecting the facial, mouth, and tongue muscles².

Choice B reason : Fine hand tremors and pill rolling are more commonly associated with Parkinson's disease, which is a different type of movement disorder. While antipsychotic medications can cause extrapyramidal symptoms that resemble Parkinson's disease, these are not indicative of tardive dyskinesia².

Choice C reason : Urinary retention and constipation can be side effects of antipsychotic medications due to their anticholinergic effects. However, these are not symptoms of tardive dyskinesia, which specifically involves involuntary movements².

Choice D reason : Loud talking and pacing may be related to the underlying condition of acute psychosis or could be a behavioral side effect of antipsychotic medication, but they are not symptoms of tardive dyskinesia².

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates the need for further teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol (Haldol). The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following?

Correct Answer is A

Explanation

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