A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

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.

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.