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: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

Correct Answer: D

Rationale: Autoimmunity is when the immune system mistakenly attacks the body's own cells. Choice D is correct because it reflects this key feature - the inability to differentiate self from nonself. This leads to the immune system targeting healthy tissues. Choices A, B, and C are incorrect as they do not accurately describe autoimmunity. Choice A refers to endotoxins destroying B cells, which is not the definition of autoimmunity. Choice B mentions overproduction of reagin antibody, which is not related to autoimmunity. Choice C is incorrect as autoimmunity does not involve depression of the immune response but rather an inappropriate immune response.

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: Diagnostic reasoning. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions. A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis. B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis. D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (A) is important but not for establishing a patient's database. Checking orders (B) and ordering medications (D) are part of the treatment process and do not directly contribute to establishing the initial patient database.

Correct Answer: C

Rationale: The correct answer is C: Bacon. Bacon contains the highest kilocalorie among the given choices due to its high fat content. Fat provides 9 kilocalories per gram, while carbohydrates (like in bread and apple) provide 4 kilocalories per gram and protein (like in chicken) provides 4 kilocalories per gram. Bacon, being high in fat, has more kilocalories compared to the other choices. Summary: A: Apple - Low in fat, primarily consists of carbohydrates, hence lower in kilocalories. B: Chicken - Contains protein, lower in kilocalories compared to fat, hence not the highest kilocalorie choice. D: Bread - Mainly consists of carbohydrates, lower in kilocalories compared to fat, making it not the highest kilocalorie choice.

Correct Answer: C

Rationale: The correct answer is C because decreased pulse rate and widened pulse pressure are not signs of hypovolemia. In hypovolemia, the body tries to compensate by increasing the heart rate and narrowing the pulse pressure to maintain adequate blood flow. A is incorrect as dry mucous membranes and soft eyeballs are signs of dehydration. B is incorrect as increased hematocrit and hemoglobin are indicators of hemoconcentration in hypovolemia. D is incorrect as increased lethargy and confusion can be seen in severe hypovolemia due to poor perfusion of vital organs.

Correct Answer: A

Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action. Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.