A client with a history of anxiety and depression presents to the emergency department with a headache, nausea, and vomiting. The client's vital signs are temperature 100.9°F (38.3°C), heart rate 115 beats/minute, respirations 21 breaths/minute, and blood pressure 216/108 mm Hg. When reviewing the client's medications, which information is of most concern to the nurse?
Hydrochlorothiazide 12.5 mg PO daily.
Phenelzine 60 mg PO daily.
Losartan 50 mg PO daily.
Aspirin 81 milligrams PO daily.
The Correct Answer is B
Choice A rationale: Hydrochlorothiazide is a diuretic and may contribute to electrolyte imbalances, but it is not the most concerning medication in this situation. Choice B rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and the combination of an MAOI with certain foods or medications containing tyramine can lead
to a hypertensive crisis. The client's elevated blood pressure is of concern, and the nurse should notify the healthcare provider.
Choice C rationale: Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. While it may contribute to blood pressure control, it is not the most concerning medication in this scenario.
Choice D rationale: Aspirin, at a dose of 81 milligrams, is often used for cardiovascular prophylaxis and is not the most concerning medication in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Headaches can be associated with various factors and are not specific to depression.
Choice B rationale: Back pain can have multiple causes and is not specific to depression. Choice C rationale: Dizziness may have various causes and is not specific to depression. Choice D rationale: Excessive tiredness (fatigue) is a common symptom of depression and often associated with the overall low energy levels experienced by individuals with depressive disorders.
Correct Answer is C
Explanation
Choice A rationale: Initiating an exercise program may be a helpful intervention, but the primary goal for this client following a drug overdose and romantic relationship issues is to return to the previous level of functioning.
Choice B rationale: Identifying positive personal traits is a positive goal but may not be the most immediate priority for this client.
Choice C rationale: Returning to the previous level of functioning is the primary goal for hospitalization. This goal involves restoring the client's ability to manage daily life and cope with stressors.
Choice D rationale: Describing what is needed in a romantic relationship is important, but the immediate focus is on the client's overall functioning and safety.
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