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: Compulsive, ritualistic behaviors are characteristic of obsessive-compulsive disorder, not schizophrenia. Schizophrenia involves disorganized thinking, often manifesting as illogical responses. Ritualistic behaviors are less typical, making this incorrect for identifying a behavior characteristic of schizophrenia in an acute care setting.

Choice B reason: Illogical answers reflect disorganized thinking, a core symptom of schizophrenia, particularly in acute phases. This is due to impaired thought processes, a hallmark of the disorder, aligning with psychiatric diagnostic criteria. This behavior is characteristic and observable during admission assessment, making it the correct choice.

Choice C reason: Suicidal thoughts may occur in schizophrenia but are not specific to it, as they appear in many psychiatric conditions. Illogical responses are more characteristic of schizophrenia’s cognitive disorganization. This choice is less precise, making it incorrect for a defining schizophrenia behavior.

Choice D reason: Depression followed by euphoria suggests bipolar disorder, not schizophrenia. Schizophrenia involves persistent psychotic symptoms like disorganized thinking, not mood swings. Illogical answers better represent schizophrenia’s thought disorder, making this incorrect for a characteristic behavior in an acute care schizophrenia admission.