A behavioral health unit nurse is caring for a newly admitted client.

Exhibits

Complete the following sentence by using the lists of options:

The client demonstrates risk for

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due to

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.

When educating the client about their medication, the nurse should teach the client that there is a risk for hypertensive crisis due to ingestion of tyramine.

Choice A: Hypertensive Crisis

Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.

Choice B: Tardive Dyskinesia

Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.

Choice C: Rhabdomyolysis

Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.

Choice D: Infection

Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.

Choice E: Nervous System Instability

Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.

Choice A: Hypertensive Crisis

Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.

Choice B: Tardive Dyskinesia

Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.

Choice C: Rhabdomyolysis

Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.

Choice D: Infection

Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.

Choice E: Nervous System Instability

Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.

Choice A reason:
Telling a client that they cannot refuse treatment because they were admitted involuntarily is incorrect. Even if a client is admitted involuntarily, they still have the right to refuse treatment unless they are deemed incompetent or a danger to themselves or others. It is essential to respect the client's autonomy and rights.

Choice B reason:
While it may be true that the client could feel better after ECT, this statement dismisses the client's current concerns and does not acknowledge their right to refuse treatment. It is important to address the client's feelings and provide support rather than making promises about the outcome.

Choice C reason:
This is the correct response because it respects the client's decision and autonomy. It also involves the provider, who can discuss the decision with the client, provide more information, or explore other options. It is a nurse's responsibility to communicate the client's decisions to the provider.

Choice D reason:
Administering medication to help the client relax without addressing their concerns about the treatment is not appropriate. It does not respect the client's right to refuse treatment and could be considered coercive.