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 B
Explanation
Choice A rationale: The client should avoid all alcohol, not limit consumption to one drink per day.
Choice B rationale: Avoiding all alcohol-containing products while on disulfiram is crucial to prevent a severe reaction called the disulfiram-alcohol reaction.
Choice C rationale: Operating heavy machinery is not a specific concern with disulfiram; avoiding alcohol is the primary focus.
Choice D rationale: Disulfiram can be taken with or without food, and taking it on an empty stomach is not necessary.
Correct Answer is D
Explanation
Choice A rationale: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.
Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.
Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.
Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.
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