A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

The correct answer is c. Recent head injury.

Rationale for choice c:

• Bupropion lowers the seizure threshold.
• Individuals with a history of head injury have an increased risk of seizures.
• Administration of bupropion to a client with a recent head injury could significantly elevate the risk of seizure activity.
• It's crucial for the provider to be aware of this risk and make an informed decision about whether to prescribe bupropion or consider alternative smoking cessation therapies.

Rationale for choice a:

• Hepatitis B infection does not generally contraindicate the use of bupropion.
• However,it's important to inform the provider of any underlying medical conditions for comprehensive assessment and management.

Rationale for choice b:

• Knee arthroplasty 1 month ago is not a contraindication for bupropion use.
• While pain management following surgery might be a consideration,bupropion is not known to interact with common analgesics used post-operatively.

Rationale for choice d:

• Hypothyroidism also does not contraindicate bupropion use.
• However,thyroid hormone levels should be monitored as bupropion may potentially impact thyroid function in some individuals.

The correct answer is Choice b, Blood pressure.

Rationale for Choice a, Bowel sounds:

• Bowel sounds are not directly relevant to the potential interaction between phenelzine and pepperoni pizza.
• While assessing bowel sounds is a part of a comprehensive nursing assessment,it would not be the top priority in this specific scenario.
• Phenelzine does not typically cause gastrointestinal disturbances that would warrant immediate assessment of bowel sounds.

Rationale for Choice c, Oxygen saturation:

• Oxygen saturation is not directly affected by the interaction between phenelzine and pepperoni pizza.
• Assessing oxygen saturation would be more pertinent in situations involving respiratory distress or hypoxia.
• There is no evidence to suggest that this interaction would cause respiratory depression or compromise oxygen saturation levels.

Rationale for Choice d, Pupil response:

• Pupil response is not a reliable indicator of the potential complications associated with phenelzine and tyramine-rich foods.
• It's primarily assessed for neurological conditions or drug intoxication affecting the central nervous system.
• The interaction between phenelzine and tyramine primarily affects the cardiovascular system,not the neurological system.

Rationale for Choice b, Blood pressure:

• Blood pressure is the most critical assessment in this scenario due to the potential for a hypertensive crisis.
• Phenelzine is a monoamine oxidase inhibitor (MAOI),which blocks the breakdown of tyramine,a substance found in certain foods like pepperoni,aged cheeses,and fermented products.
• When tyramine levels increase,it can trigger a sudden and severe rise in blood pressure,known as a hypertensive crisis.
• Symptoms of a hypertensive crisis can include:
  • Severe headache
  • Neck stiffness
  • Chest pain
  • Nausea
  • Vomiting
  • Blurred vision
  • Sweating
  • Photophobia (sensitivity to light)
  • Palpitations
  • Anxiety
  • Confusion
  • Seizures
  • Stroke
  • Potentially death
• Prompt assessment of blood pressure is crucial for early detection and intervention to prevent these life-threatening complications.