A nurse in an outpatient mental health facility is preparing to administer phenelzine to a client who has been taking this medication for several years. The client reports eating a grilled cheese sandwich and a banana for lunch and is feeling dizzy. Which of the following vital signs should the nurse assess first?

Blood pressure

Respiration

Pulse

Temperature

Answer and Explanation

The Correct Answer is A

Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.

Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.

Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.

Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.

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Free Nursing Study Resources

Correct Answer is ["1.4"]

Explanation

Step 1 is to identify the required dose, which is 7 mg of haloperidol.

Step 2 is to identify the concentration of the available haloperidol injection, which is 5 mg/mL.

Step 3 is to calculate the volume to be administered using the formula: Volume = Dose ÷ Concentration.

So, let's calculate:

Volume = 7 mg (Dose) ÷ 5 mg/mL (Concentration)

This gives us:

Volume = 1.4 mL

However, we need to round the answer to the nearest tenth and use a leading zero if it applies. So, the final volume to be administered is 1.4 mL. The nurse should administer 1.4 mL of haloperidol injection.

A. Caution the client against feeling angry at the sibling. B. Recommend that the client participate in more solitary activities. C. Explain to the client that the duration of grief is highly variable and can last for years. D. Encourage the client to avoid discussing the events surrounding the sibling's death.

Correct Answer is C

Explanation

Choice A reason: Cautioning the client against feeling angry at the deceased sibling could invalidate the client's natural grieving process. Anger is a common and expected emotion in the stages of grief, and acknowledging it can be therapeutic. It is important for the nurse to provide a safe space for the client to express all emotions related to their loss.

Choice B reason: Recommending more solitary activities might not be beneficial for a client experiencing depression after a significant loss. Social support and engagement in social activities can be crucial for recovery. Isolation can exacerbate feelings of loneliness and depression. Instead, the nurse should encourage the client to maintain connections with supportive friends and family members.

Choice C reason: Explaining that the duration of grief is highly variable and can last for years is important. Grief does not have a set timeline, and individuals experience it differently. Providing this information can help normalize the client's feelings and reassure them that what they are experiencing is a part of the healing process.

Choice D reason: Encouraging the client to avoid discussing the events surrounding the sibling's death can hinder the grieving process. Open communication about the loss and the associated emotions is essential for healing. The nurse should encourage the client to share their feelings and memories when they feel ready, as this can be a part of the therapeutic process.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 7 mg of haloperidol IM to a client who is severely agitated. Haloperidol injection of 5 mg/mL is available. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.4"]

Explanation

A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reviewing the day 5 vital signs. Exhibits A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when supporting the client's refusal of medications?

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following pieces of information should the nurse include?

A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral anti-anxiety medication. Which of the following actions should the nurse take?

A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

Exhibits A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. Which of the following individuals should the nurse ask to assist with communication?