Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Encourage visits from family members: While family presence can help reduce anxiety and reorient clients with delirium, it is not the immediate first step. Before implementing supportive strategies, the nurse must first assess the client’s neurological status to determine the severity and possible cause of the delirium.

B. Administer an anxiolytic medication: Administering medications should not be the first action because delirium can be caused by multiple reversible factors. Sedating a client without identifying the underlying cause may worsen confusion or mask important symptoms that need immediate intervention.

C. Determine the client's level of consciousness: Assessing the client’s level of consciousness is the priority because it provides critical information about the severity of the delirium and helps guide immediate and appropriate interventions. Early assessment ensures that life-threatening conditions, such as hypoxia or sepsis, are not overlooked.

D. Keep lights on in the client's room: Maintaining a well-lit environment can help prevent disorientation, especially at night, but it is a secondary supportive measure. Assessment of mental status must occur first to prioritize safety and identify urgent medical needs.

A. Dry excess sanitizer from hands with a paper towel B. Rubs hands together for 10 seconds after applying sanitizer C. Apply enough sanitizer to completely cover both hands D. Clean sanitizer from under fingernails using an orangewood stick

Correct Answer is C

Explanation

A. Dry excess sanitizer from hands with a paper towel: Hand sanitizer should be allowed to dry naturally, and there is no need to wipe it off with a paper towel. Wiping off the sanitizer could reduce its effectiveness in killing germs.

B. Rubs hands together for 10 seconds after applying sanitizer: The Centers for Disease Control and Prevention (CDC) recommends rubbing hands together for at least 20 seconds to ensure that the hand sanitizer covers all surfaces of the hands and effectively kills germs.

C. Apply enough sanitizer to completely cover both hands: It is important to apply a sufficient amount of hand sanitizer (usually about a dime-sized amount) to cover both hands entirely. The sanitizer should be rubbed into all areas of the hands, including between fingers and under nails, until the hands are dry.

D. Clean sanitizer from under fingernails using an orangewood stick: This is unnecessary if the sanitizer is applied properly and rubbed in completely. Hand sanitizer should be used to cover all areas of the hands, including under fingernails, and should be allowed to dry naturally without needing to clean it with a stick.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is assisting with the development of a staff in-service about hand hygiene. The nurse should include which of the following instructions regarding the use of hand sanitizer?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client. The nurse is collecting data from the client. Select words from the choices below to fill in each blank in the following sentence. The nurse should identify that _______ and __________ indicate manifestations of borderline personality disorder.

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

A nurse is administering an enteric-coated medication to an adult client who has right-sided weakness and is having difficulty swallowing tablet. Which of the following actions should the nurse take?

A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?

A nurse is reinforcing teaching with a guardian about receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse include as a potential effect of the medication?