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A nurse is assisting in the care of a client in an outpatient mental health clinic.

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again.

Nurses' Notes

Today:

Client states, "I'm feeling much better." They report less fatigue, even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation.

Vital Signs

Today:

Blood pressure 169/91 mm Hg

Heart rate 78/min

Respiratory rate 18/min

even though they have difficulty sleeping

experiencing more frequent headaches

Blood pressure 169/91 mm Hg

Client continues to deny any suicidal ideation

Heart rate 78/min

Respiratory rate 18/min

Answer and Explanation

The Correct Answer is ["A","B","C"]

Frequent headaches: Phenelzine, an MAOI, can cause hypertensive crisis, with one of the earliest signs being persistent or worsening headaches. Frequent headaches must be treated as a possible warning of dangerously elevated blood pressure and require immediate provider notification.
Elevated blood pressure (169/91 mm Hg): The significant rise in the client's blood pressure compared to baseline indicates new-onset hypertension. This is a serious adverse effect associated with MAOIs and signals the potential development of a hypertensive crisis, which must be urgently addressed.
Difficulty sleeping: Difficulty sleeping or insomnia is a common side effect of phenelzine and other antidepressants. Although not life-threatening, insomnia can impair recovery if untreated and should be documented and discussed with the provider to adjust management if needed.
Feeling much better: Improvement in mood and reduced fatigue are intended therapeutic outcomes of phenelzine treatment. These findings are positive signs and do not indicate an adverse reaction that needs intervention.
Heart rate 78/min and respiratory rate 18/min: Both values are within normal ranges and do not suggest immediate concerns related to cardiovascular or respiratory function. They should continue to be monitored but do not require urgent action.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is []

Explanation

Prepare the client for an emergency cesarean birth: Emergency cesarean delivery is indicated in cases of fetal distress or placenta previa with severe bleeding at term. In a hydatidiform mole, there is no viable fetus, and the priority is evacuation of the molar tissue rather than delivery by cesarean section.
Prepare the client for suction curettage: Suction curettage is the treatment of choice for a hydatidiform mole. It allows for the complete evacuation of abnormal trophoblastic tissue, preventing complications such as severe hemorrhage and progression to malignant gestational trophoblastic disease.
Anticipate a prescription for methotrexate: Methotrexate is primarily used to treat ectopic pregnancies or persistent gestational trophoblastic disease after a molar pregnancy, not for initial management. Immediate evacuation of the mole by suction curettage is the first-line intervention for this client.
Remind the client that weekly blood tests are needed to measure pregnancy hormone: Following a molar pregnancy, weekly beta-hCG tests are critical to monitor for residual trophoblastic tissue or the development of choriocarcinoma. A declining beta-hCG confirms the resolution of disease, while a plateau or rise indicates persistent disease.
Administer terbutaline: Terbutaline is a tocolytic medication used to relax the uterus in cases of preterm labor. In the case of a hydatidiform mole, uterine evacuation is necessary rather than uterine relaxation, making terbutaline inappropriate for this situation.
Vaginal bleeding: Clients with a hydatidiform mole are at risk for significant vaginal bleeding due to the abnormal growth of trophoblastic tissue. Monitoring the amount and type of vaginal bleeding helps detect hemorrhage or retained molar tissue requiring urgent intervention.
Blood pressure: Elevated blood pressure is a potential complication of hydatidiform mole, similar to preeclampsia, and can occur even in the first or second trimester. Regular monitoring of blood pressure is essential to detect worsening hypertensive symptoms early.
Uterus for hypertonicity: Hypertonicity of the uterus is typically monitored in cases of labor or uterine rupture concerns. In a hydatidiform mole, the uterus is distended by abnormal tissue but hypertonicity is not a primary concern needing monitoring in this condition.
Unilateral pelvic pain: Unilateral pelvic pain is more characteristic of ectopic pregnancy rather than a molar pregnancy. In hydatidiform mole, generalized uterine enlargement and discomfort are more typical, so unilateral pelvic pain is not a focus for this client.
Cervical dilation per provider: Cervical dilation is not the main indicator of progress or concern with a molar pregnancy. The focus is on removing molar tissue and monitoring beta-hCG levels, not on the progress of cervical changes like in labor.

A. Lung assessment B. Vertigo C. Facial nerve assessment D. Pain rating E. Diminished hearing F. Pupils

Correct Answer is ["B","C","D","E"]

Explanation

Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Which of the following findings requires further action by the nurse? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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A nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?