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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Transference is a defense mechanism in which the client unconsciously transfers feelings, attitudes, or impulses from a past relationship to a current one, such as a health care provider. The nurse should recognize this behavior and maintain professional boundaries with the client. The other options are not specific to transference and may indicate other issues.
Correct Answer is B
Explanation
Choice A reason:
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
Choice B reason:
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
Choice C reason:
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
Choice D reason:
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.
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