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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I'm sorry to hear that, but I know the dialysis will make you feel better.": This response dismisses the client’s feelings and moves too quickly to reassurance without first exploring the client’s perspective. It can make the client feel unheard and pressured to accept the treatment.
B. "What are your concerns about the dialysis treatments?": This response encourages open communication by inviting the client to express their fears, concerns, or misunderstandings. It shows respect for the client's autonomy and fosters a therapeutic relationship built on trust and understanding.
C. "Do you think your doctor would have recommended dialysis if you didn't need it?": This shifts focus away from the client’s feelings and places undue emphasis on the authority of the provider. It may make the client feel invalidated or coerced rather than supported in making an informed decision.
D. "Most people do get tired of dialysis treatments after a while.": This statement reinforces negative feelings about dialysis and can increase the client’s anxiety or resistance toward the treatment rather than helping them work through their concerns in a constructive manner.
Correct Answer is B
Explanation
A. "A client must sign an Against Medical Advice form if he withdraws consent.": An Against Medical Advice (AMA) form is specifically used when a client chooses to leave a healthcare facility against medical advice, not when they withdraw consent for a procedure. Withdrawing consent does not require an AMA form and follows a separate legal and ethical process.
B. "A client can withdraw consent at any time after signing the informed consent form.": Clients maintain the right to autonomy throughout their care, including the right to withdraw consent at any point before or during a procedure. Signing the form does not waive their right to change their mind, and healthcare providers must respect this decision without penalizing the client.
C. "A client who is involuntarily admitted to a mental health unit cannot withdraw consent for treatment.": Even clients who are involuntarily admitted retain certain rights, including the right to refuse specific treatments unless they are legally deemed incompetent or pose an imminent threat. Involuntary admission does not mean automatic consent to all treatments.
D. "A client must provide a written refusal for a procedure for which he has already signed an informed consent.": Clients can verbally withdraw consent at any time; a written refusal is not legally required. While documentation of the client's decision is necessary for the medical record, insisting on a written refusal is not a legal prerequisite for withdrawal of consent.
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