To evaluate the effectiveness of nitroglycerin 0.4 mg SL administered to a client diagnosed with angina pectoris, the nurse should:
Assess if the client's urine output has increased.
Ask the client if chest pain is relieved.
Take the client's blood pressure.
Ask the client to ambulate and assess for the absence of dyspnea.
The Correct Answer is B
Choice A Reason
Increased urine output is not a direct indicator of the effectiveness of nitroglycerin for angina pectoris. Nitroglycerin is a vasodilator used primarily to relieve chest pain by improving blood flow to the heart muscle, not to influence urine production.
Choice B Reason
Asking the client if their chest pain has been relieved is the most direct method of evaluating the effectiveness of nitroglycerin. Relief of chest pain indicates that the medication is working as intended, reducing the ischemia that causes angina.
Choice C Reason
While taking the client's blood pressure is important, especially since nitroglycerin can cause hypotension, it is not the primary method for evaluating the effectiveness of the medication in relieving angina. Blood pressure measurements are more of a safety check to monitor for adverse effects.
Choice D Reason
Ambulation and assessing for the absence of dyspnea can be part of an overall evaluation of the client's cardiovascular status, but they are not specific to evaluating the effectiveness of nitroglycerin for angina relief. Dyspnea may be a symptom of heart failure or other conditions, not specifically angina pectoris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Isoniazid, an antitubercular medication, can cause peripheral neuropathy, a form of nerve damage characterized by numbness, tingling, or pain, particularly in the hands and feet. This side effect is due to the drug's interference with the normal metabolism of vitamin B6 (pyridoxine). Supplementation with vitamin B6 is recommended to prevent this complication. The normal daily recommended intake for vitamin B6 in adults ranges from 1.3 to 1.7 mg.
Choice B reason:
While it is true that isoniazid can cause discoloration of bodily fluids, turning urine and tears orange, this is not a harmful side effect and does not require intervention. It is, however, important to inform the client of this possibility to prevent alarm.
Choice C reason:
There is no evidence to suggest that routine hearing exams are necessary for clients taking isoniazid unless they have pre-existing hearing conditions or are taking other medications known to affect hearing. Therefore, this is not a standard part of the teaching plan for clients on isoniazid.
Choice D reason:
Photosensitivity reactions are not commonly associated with isoniazid use. While wearing sunscreen is generally good advice for skin protection, it is not specifically related to the administration of isoniazid and thus would not be the primary information to include in the teaching plan.
Correct Answer is D
Explanation
Choice A Reason
Hyperreflexia refers to an overactive or overresponsive reflexes, which is a neurological condition and not directly related to the behaviors described. It is typically seen in conditions affecting the central nervous system and is not characterized by the inability to wait turns or interrupting conversations.
Choice B Reason
Defiance implies a conscious choice to resist authority or rules, which may not necessarily be the case here. While children with behavioral issues may exhibit defiant behaviors, the symptoms described are more indicative of a lack of impulse control rather than a deliberate choice to defy.
Choice C Reason
Inattention is a component of several behavioral and cognitive disorders, including ADHD. However, the behaviors described—blurting out answers, inability to wait for turns, and interrupting others—are more specifically associated with impulsivity rather than inattention alone.
Choice D Reason
Impulsivity is the tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. The behaviors described—such as blurting out answers and interrupting others—are classic signs of impulsivity, which is often seen in conditions like ADHD.
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