A client is admitted with a diagnosis of major depression and states, “Nothing brings me pleasure anymore.” Which behaviors will the nurse assess that correlate with the diagnosis?

Choice A reason: Assessing past suicide attempts provides risk context but is not the immediate priority. Current suicidal ideation requires urgent action to ensure safety, as past history does not address the acute risk of self-harm, making this secondary to implementing protective measures.

Choice B reason: Notifying the treatment team and initiating suicide precautions is the priority to ensure immediate safety. Suicidal ideation indicates a high risk of self-harm, requiring team coordination, constant observation, and environmental safety measures to prevent harm and ensure timely intervention.

Choice C reason: Identifying coping mechanisms is part of long-term suicide prevention but is not the priority during active suicidal ideation. Immediate safety measures, such as precautions and team notification, are critical to prevent harm before addressing coping strategies in therapy.

Choice D reason: Determining a specific suicide plan is important for risk assessment but is secondary to initiating immediate safety measures. Suicide precautions and team notification ensure the client’s safety first, allowing for subsequent detailed evaluation of the ideation’s specificity and intent.

Choice A reason: Phenelzine, an MAOI, inhibits monoamine oxidase, leading to tyramine accumulation. Tyramine-rich foods like blue cheese, red wine, and raisins can cause hypertensive crises by triggering norepinephrine release, leading to dangerous blood pressure spikes, making this the correct dietary restriction advice.

Choice B reason: Milk, peanuts, and tomatoes are not high in tyramine and do not interact significantly with phenelzine. These foods are generally safe for clients on MAOIs, as they do not trigger the hypertensive crises associated with tyramine-rich foods, making this incorrect.

Choice C reason: Shellfish, grapefruit, and egg yolks are not tyramine-rich and do not pose a significant risk with phenelzine. Grapefruit affects cytochrome P450 enzymes, not MAOIs, and shellfish and egg yolks are safe, making this an incorrect dietary restriction.

Choice D reason: Juice, pears, and black beans are low in tyramine and safe for clients taking phenelzine. They do not cause the hypertensive crises associated with MAOI-related ty/annine interactions, making this an incorrect choice for foods to avoid.