A client who was admitted 3 days ago for a bowel obstruction has a liter of lactated Ringer’s with potassium chloride (KCl) 20 mEq infusing. The client has been receiving selegiline for depression. When the client reports experiencing a severe headache, the nurse obtains a blood pressure of 200/110 mm Hg. Which action(s) should the nurse take? (Select all that apply)

Choice A reason: Selegiline, an MAOI, can cause hypertensive crisis, especially with dietary tyramine or drug interactions. Withholding the next dose prevents further escalation of the client’s severe hypertension (200/110 mm Hg), aligning with pharmacology protocols for MAOI-related crises, making this a critical nursing action.

Choice B reason: Monitoring blood pressure and pulse every 15 minutes tracks the client’s hypertensive crisis, ensuring timely detection of changes in this life-threatening condition. Frequent vital signs are essential for managing MAOI-induced hypertension, aligning with critical care standards, making this an appropriate action.

Choice C reason: Measuring hourly urinary output is relevant for fluid status but not urgent in a hypertensive crisis. Blood pressure monitoring and provider notification address the immediate danger of selegiline’s effects, making urinary output less critical and incorrect for this acute scenario’s priority actions.

Choice D reason: Discontinuing the IV infusion is unnecessary, as lactated Ringer’s with KCl is not causing the hypertension. Selegiline’s MAOI effects are the likely culprit. Stopping the IV risks fluid imbalance without addressing the crisis, making this incorrect for managing the client’s condition.

Choice E reason: Notifying the healthcare provider is essential, as the client’s severe headache and hypertension (200/110 mm Hg) suggest an MAOI-related crisis requiring urgent medical intervention. This ensures rapid management, aligning with patient safety protocols, making it a critical action for the nurse to take.

Choice A reason: Identifying transference assumes the client’s behavior caused the nurse’s anger, which may not be accurate. Terminating the session prevents untherapeutic escalation, allowing the nurse to regain composure. This choice risks misattributing emotions, making it incorrect for managing the nurse’s immediate anger.

Choice B reason: Resolving feelings after discharge delays addressing the nurse’s current anger, risking unprofessional behavior during the session. Terminating the session maintains therapeutic boundaries, making this incorrect, as it postpones action needed to manage the immediate emotional reaction effectively.

Choice C reason: Sharing personal experiences is untherapeutic and shifts focus from the client, potentially worsening the nurse’s anger. Terminating the session preserves professionalism and boundaries, making this incorrect, as self-disclosure does not address the nurse’s emotional state or maintain a therapeutic environment.

Choice D reason: Terminating the session before anger escalates allows the nurse to regain composure, preserving therapeutic boundaries and preventing unprofessional behavior. This action prioritizes client care and nurse self-awareness, aligning with psychiatric nursing ethics, making it the best choice for managing the nurse’s emotions.