A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Oxygen saturation

Blood pressure

Pupil response

Bowel sounds

Answer and Explanation

The Correct Answer is B

Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause a hypertensive crisis if taken with foods that contain tyramine, such as pepperoni pizza. The nurse should assess the client's blood pressure to monitor for signs of hypertension, such as headache, chest pain, or blurred vision.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Positive symptoms of schizophrenia are those that add something to the normal experience, such as hallucinations, delusions, disorganized speech, and abnormal motor behavior. Flight of ideas is a type of disorganized speech that involves rapid switching from one topic to another. Delusions of grandeur are false beliefs of having superior power or status. Auditory hallucinations are hearing voices or sounds that are not real. Negative symptoms of schizophrenia are those that take something away from the normal experience, such as decreased motivation, impaired memory, flat affect, and social withdrawal.

A. Lanugo covering the body B. +2 edema of the lower extremities C. BUN 21 mg/dL D. Blood pH 7.60

Correct Answer is D

Explanation

A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.

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A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?

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