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NurseDive Free Nursing Practice Question
A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?
A. "Take only one dose of nitroglycerin to reduce the risk of getting a headache."
"Take only one dose of nitroglycerin to reduce the risk of getting a headache." This statement is incorrect because it may compromise the effectiveness of nitroglycerin in relieving angina. The client should follow the prescribed dosage and frequency of nitroglycerin, which is usually one tablet every 5 minutes for up to three doses, as needed for chest pain.
B. "There's nothing that can be done to relieve the headaches that nitroglycerin causes."
"There's nothing that can be done to relieve the headaches that nitroglycerin causes." This statement is incorrect because it is discouraging and dismissive of the client's concern. The nurse should acknowledge the client's discomfort and offer suggestions for managing the side effect, such as taking a mild analgesic or lying down in a dark room.
C. "We will ask the provider to prescribe a different medication for you."
"We will ask the provider to prescribe a different medication for you." This statement is incorrect because it implies that nitroglycerin is not suitable for the client and may cause unnecessary anxiety or confusion. The nurse should explain that nitroglycerin is an effective and safe medication for angina and that the headache is a common and transient side effect that can be managed with simple measures. The nurse should also inform the client that there are other forms of nitroglycerin, such as patches or sprays, that may have less headache-inducing effects. However, changing the medication or the route of administration should be done only after consulting with the provider.
D. "Try taking a mild analgesic to relieve the headache."
Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces myocardial oxygen demand. It is used to treat and prevent angina atacks. A common side effect of nitroglycerin is headache, which is caused by cerebral vasodilation. The nurse should advise the client to take a mild analgesic, such as acetaminophen, to relieve the headache. The headache usually subsides with continued use of nitroglycerin.
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Full Explanation
Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces myocardial oxygen demand. It is used to treat and prevent angina atacks. A common side effect of nitroglycerin is headache, which is caused by cerebral vasodilation. The nurse should advise the client to take a mild analgesic, such as acetaminophen, to relieve the headache. The headache usually subsides with continued use of nitroglycerin.
The other options are not correct because:
"Take only one dose of nitroglycerin to reduce the risk of getting a headache." This statement is incorrect because it may compromise the effectiveness of nitroglycerin in relieving angina. The client should follow the prescribed dosage and frequency of nitroglycerin, which is usually one tablet every 5 minutes for up to three doses, as needed for chest pain.
"There's nothing that can be done to relieve the headaches that nitroglycerin causes." This statement is incorrect because it is discouraging and dismissive of the client's concern. The nurse should acknowledge the client's
discomfort and offer suggestions for managing the side effect, such as taking a mild analgesic or lying down in a dark room.
"We will ask the provider to prescribe a different medication for you." This statement is incorrect because it implies that nitroglycerin is not suitable for the client and may cause unnecessary anxiety or confusion. The nurse should explain that nitroglycerin is an effective and safe medication for angina and that the headache is a common and transient side effect that can be managed with simple measures. The nurse should also inform the client that there are other forms of nitroglycerin, such as patches or sprays, that may have less headache-inducing effects. However, changing the medication or the route of administration should be done only after consulting with the provider.
Similar Questions
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?
A. Dyspnea
Dyspnea is a difficulty or labored breathing that can be caused by various respiratory or cardiac conditions, such as asthma, pneumonia, pulmonary edema, or heart failure. It is not a specific sign of hypokalemia, although severe hypokalemia can affect respiratory muscle function and cause respiratory failure.
B. Oliguria
Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. It can be caused by various renal or fluid balance disorders, such as acute kidney injury, dehydration, or shock. It is not a specific sign of hypokalemia, although severe hypokalemia can impair renal function and cause renal failure.
C. Pitting edema
Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. It can be caused by various fluid retention disorders, such as heart failure, liver cirrhosis, or nephrotic syndrome. It is not a specific sign of hypokalemia, although severe hypokalemia can affect fluid and electrolyte balance and cause edema.
D. Fatigue
Full Explanation
Hypokalemia is a low serum potassium level, usually below 3.5 mEq/L. It can be caused by diuretics that increase potassium excretion, such as thiazides or loop diuretics. Potassium is essential for normal muscle and nerve function, and hypokalemia can impair cardiac, skeletal, and smooth muscle activity. Symptoms of hypokalemia include fatigue, weakness, muscle cramps, arrhythmias, constipation, and hyporeflexia.
- Dyspnea is difficulty or labored breathing that can be caused by various respiratory or cardiac conditions, such as asthma, pneumonia, pulmonary edema, or heart failure. It is not a specific sign of hypokalemia, although severe hypokalemia can affect respiratory muscle function and cause respiratory failure.
- Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. It can be caused by various renal or fluid balance disorders, such as acute kidney injury, dehydration, or shock. It is not a specific sign of hypokalemia, although severe hypokalemia can impair renal function and cause renal failure.
- Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. It can be caused by various fluid retention disorders, such as heart failure, liver cirrhosis, or nephrotic syndrome. It is not a specific sign of hypokalemia, although severe hypokalemia can affect fluid and electrolyte balance and cause edema.
A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?
A. "Use simple, childlike statements when speaking."
Using simple language is helpful, but speaking in a childlike manner can be demeaning and may lower the client’s self-esteem. Communication should remain respectful and age-appropriate.
B. "Incorporate nonverbal cues in the conversation."
Incorporating nonverbal cues such as gestures, facial expressions, pictures, and written words supports understanding. Clients with aphasia often benefit from visual aids and other alternative communication strategies to enhance comprehension.
C. "Use a higher-pitched tone of voice when speaking."
Raising the pitch of the voice does not improve comprehension in aphasia because the issue is related to language processing rather than hearing ability. A normal tone should be maintained unless the client has a hearing impairment.
D. "Ask multiple choice questions as part of the conversation."
Asking multiple-choice questions can sometimes assist with expressive aphasia; however, relying solely on this method may limit natural communication. The broader and more supportive approach is to incorporate nonverbal communication techniques.
Full Explanation
A. Using simple language is helpful, but speaking in a childlike manner can be demeaning and may lower the client’s self-esteem. Communication should remain respectful and age-appropriate.
B. Incorporating nonverbal cues such as gestures, facial expressions, pictures, and written words supports understanding. Clients with aphasia often benefit from visual aids and other alternative communication strategies to enhance comprehension.
C. Raising the pitch of the voice does not improve comprehension in aphasia because the issue is related to language processing rather than hearing ability. A normal tone should be maintained unless the client has a hearing impairment.
D. Asking multiple-choice questions can sometimes assist with expressive aphasia; however, relying solely on this method may limit natural communication. The broader and more supportive approach is to incorporate nonverbal communication techniques.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
A. History of neurologic deficits lasting less than 1 hr
History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood flow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood flow to the affected area.
B. Maintains consciousness
Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
C. Manifestations preceded by a severe headache
D. Gradual onset of several hours
Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.
Full Explanation
- A hemorrhagic stroke is a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. A common cause of hemorrhagic stroke is a cerebral aneurysm, which is a weak or bulging spot in an artery wall. When an aneurysm ruptures, it causes sudden and severe bleeding in the brain, which can damage brain cells and increase intracranial pressure. Symptoms of a hemorrhagic stroke include a sudden and severe headache, often described as "the worst headache of my life", followed by neurologic deficits, such as weakness, numbness, vision loss, speech problems, confusion, or loss of consciousness
- The other options are not correct because:
- History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood flow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood flow to the affected area.
- Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
- Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.