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
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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Related Questions
Correct Answer is A
Explanation
Choice A reason: Chlordiazepoxide is a benzodiazepine that is commonly used to treat the symptoms of acute alcohol withdrawal. It works by enhancing the effect of the neurotransmitter GABA, which has an overall calming effect on the nervous system. This helps to reduce the severity of withdrawal symptoms such as anxiety, agitation, and the risk of seizures.
Choice B reason: Buprenorphine is an opioid partial agonist-antagonist used primarily to treat opioid addiction and is not typically used for alcohol withdrawal. While it can help with some withdrawal symptoms, it does not address the full spectrum of alcohol withdrawal symptoms and is not the standard treatment for this condition.
Choice C reason: Bupropion is an antidepressant and smoking cessation aid. It affects neurotransmitters in the brain but is not indicated for the treatment of alcohol withdrawal. Therefore, it would not be the expected medication for managing acute alcohol withdrawal symptoms.
Choice D reason: Disulfiram is used as a deterrent agent in the management of chronic alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed, which helps to maintain abstinence but is not used for treating acute withdrawal symptoms.
Correct Answer is A
Explanation
Choice A reason: Listing the negative effects of alcohol use can help the client gain insight into the consequences of their actions and reinforce their motivation to remain sober. Reflecting on personal losses and health issues due to alcohol can be a powerful deterrent against relapse.
Choice B reason: While attending support group meetings can be beneficial, saying "as needed" may not provide the structured support necessary for preventing relapse. Regular attendance at support groups like Alcoholics Anonymous (AA) is often recommended for sustained recovery.
Choice C reason: Lorazepam is not typically prescribed to prevent relapse in alcohol use disorder due to its potential for abuse and dependence. Instead, medications like naltrexone or acamprosate may be considered to help maintain abstinence.
Choice D reason: Revisiting familiar places may trigger cravings and is generally not advised. Instead, clients are encouraged to avoid places associated with their past alcohol use to reduce the risk of relapse.
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