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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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

A. Temperature of 37.2° C (99.0°F) B. Elevated WBC count C. Pain rating of 4 on a scale of 0 to 10 D. Increased urinary output

Correct Answer is B

Explanation

A. Temperature of 37.2° C (99.0° F): A temperature of 37.2° C is within the normal range and does not necessarily indicate infection. Mild temperature elevations are common in the immediate postoperative period due to inflammatory responses rather than infection, which typically presents with more significant fever.

B. Elevated WBC count: An elevated white blood cell (WBC) count is a classic and early indicator of infection. It reflects the body's immune response to a bacterial or viral invasion, and postoperative infections often present with leukocytosis, making it a key finding to monitor closely.

C. Pain rating of 4 on a scale of 0 to 10: Moderate pain is expected after surgery and does not, by itself, suggest infection. Postoperative pain should be assessed in context with other symptoms like redness, swelling, or drainage; pain alone, especially if stable, is not definitive for infection.

D. Increased urinary output: Increased urinary output is generally a positive sign of good kidney perfusion and hydration status. A decrease, not an increase, in urinary output would be more concerning postoperatively and could suggest complications, but not necessarily infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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