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 D

Explanation

Choice A reason : Having the client floss 4 times daily is not typically recommended during chemotherapy because their gums may be more prone to bleeding due to a decrease in platelets, which is a common side effect of chemotherapy¹. Instead, gentle oral care is advised to prevent damage to the oral mucosa.

Choice B reason : Having the client swish with commercial mouthwash before therapy is not generally recommended because many commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes and may exacerbate chemotherapy-induced mucositis¹. Instead, a saline rinse or a prescribed mouthwash without alcohol may be used to help manage oral hygiene during chemotherapy.

Choice C reason : Telling the client to expect dark stools following chemotherapy could be misleading. While some chemotherapy drugs can cause changes in stool color, dark stools can also indicate gastrointestinal bleeding, which requires immediate medical attention¹. Therefore, patients should be instructed to report any significant changes in stool color to their healthcare provider.

Choice D reason : Administering an antiemetic prior to the procedure is a standard practice to prevent nausea and vomiting associated with chemotherapy¹. Antiemetics are medications that can help control these common side effects, improving the patient's comfort and ability to tolerate the treatment.

A. Tetany and complaints of stiffness of the hands. B. Exophthalmos and complaints of nervousness. C. Reports of extreme fatigue and hair loss. D. Reports of profuse sweating and flushed skin.

Correct Answer is C

Explanation

Choice A reason : Tetany and stiffness of the hands are not typical symptoms of hypothyroidism. Tetany is usually associated with hypocalcemia, which is not a direct result of hypothyroidism⁶.

Choice B reason : Exophthalmos and nervousness are symptoms associated with hyperthyroidism, not hypothyroidism. Exophthalmos, the bulging of the eyes, is particularly associated with Graves' disease, a type of hyperthyroidism⁶.

Choice C reason : Extreme fatigue and hair loss are common symptoms of hypothyroidism. The condition can lead to a slowing down of the body's metabolic processes, resulting in fatigue. Hair loss is also a frequent complaint due to the effects of reduced thyroid hormone levels on hair follicles⁶⁷⁸.

Choice D reason : Profuse sweating and flushed skin are more indicative of hyperthyroidism or other conditions, not hypothyroidism. Hypothyroidism typically leads to cold intolerance and dry skin⁶.

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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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