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: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
Correct Answer is D
Explanation
Choice A rationale: Gastric lavage may be considered, but the priority is to address respiratory depression. Naloxone administration is more immediate.
Choice B rationale: Renal dialysis is not indicated for the overdose of methadone and benzodiazepines. Addressing respiratory depression is the priority.
Choice C rationale: Nebulizing with albuterol is not the appropriate intervention for respiratory depression due to drug overdose. Naloxone administration is more critical. Choice D rationale: Administration of naloxone is the priority for this client with respiratory depression due to the potential opioid overdose (methadone). Naloxone is an opioid antagonist that can reverse opioid-induced respiratory depression.
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