Mrs. Tan was prescribed with nitroglycerin. Nurse Amalia teaches her about the common side effect of the drug which includes:

Correct Answer: D

Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use. Explanation of other choices: A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels. B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system. C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.

Correct Answer: C

Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.

Correct Answer: D

Rationale: The correct answer is D: Evaluation. After implementing nursing interventions based on priority diagnoses, the nurse must evaluate the effectiveness of these interventions to determine if the desired outcomes have been achieved. Evaluation is crucial to assess the progress, make necessary modifications, and ensure the effectiveness of the care provided. Assessment (A) is already completed before interventions are carried out. Planning (B) involves developing a care plan based on assessment findings. Implementation (C) is the actual carrying out of the interventions. Therefore, the next step after implementing nursing interventions is to evaluate their effectiveness.

Correct Answer: D

Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario. Incorrect choices: A: It will have no effect - Incorrect because infections and fever can impact insulin requirements. B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations. C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.

Correct Answer: B

Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.