A nurse is assisting with the care of a client.

Exhibits

Data Collection Findings.

For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease.

Each finding may support more than 1 disease process.

Choice A rationale:

Hyperglycemia is not typically associated with tranylcypromine, a monoamine oxidase inhibitor (MAOI) MAOIs can affect blood pressure regulation, but hyperglycemia is not a common adverse effect of this medication.

Choice B rationale:

Hematuria (blood in the urine) is not a known adverse effect of tranylcypromine. This symptom is not directly related to the use of MAOIs.

Choice C rationale:

Tinnitus (ringing in the ears) is not a common adverse effect of tranylcypromine. MAOIs can affect the cardiovascular system, but tinnitus is not a typical manifestation.

Choice D rationale:

Tranylcypromine, an MAOI, can cause hypertension (high blood pressure) as an adverse effect due to its ability to inhibit the breakdown of tyramine in the body. When tyramine-rich foods are ingested, there can be a sudden release of norepinephrine, leading to a hypertensive crisis. Therefore, monitoring for hypertension is essential when a client is taking tranylcypromine and has ingested tyramine-rich foods.

Choice A rationale:

Allowing the patient to lift the CPM machine onto the bed is not a safe practice. Arthroscopic surgery may result in limited mobility and discomfort for the patient. Lifting heavy equipment could potentially strain the surgical site or lead to injury.

Choice B rationale:

Telling the patient that CPM will not hurt at all is not accurate. While CPM is a passive motion technique aimed at preventing joint stiffness, some discomfort or mild pain may be experienced, especially during the initial sessions. Managing the patient's pain is essential to ensure compliance with the CPM exercises.

Choice C rationale:

Suggesting that the patient does not need to do CPM exercises is incorrect. CPM exercises are often prescribed after joint surgery to prevent joint stiffness, improve circulation, and aid in recovery. Discouraging the patient from participating in these exercises would be detrimental to their postoperative outcome.

Choice D rationale:

Administering an opioid analgesic to the client 30 minutes before initiating CPM exercises is the correct choice. CPM exercises can be uncomfortable for some patients, especially in the initial stages, and providing adequate pain relief before starting the exercises promotes patient comfort and compliance. It helps ensure that the patient can perform the exercises effectively without undue pain, reducing the risk of complications and promoting a successful recovery.