A nurse is caring for a 72-year-old client who suddenly becomes weak and lightheaded. The cardiac monitor shows second-degree AV block Type II. The client is pale and diaphoretic with a blood pressure of 82/48 mm Hg and a heart rate of 42 beats per minute. Which collaborative intervention should the nurse anticipate implementing?

Administer furosemide (Lasix) 80 mg IV as ordered

Administer a thrombolytic medication

Prepare for transcutaneous pacing

Prepare for synchronized cardioversion

Answer and Explanation

The Correct Answer is C

Choice A reason: Furosemide is a diuretic used for fluid overload in heart failure, not for second-degree AV block Type II, which causes bradycardia and hypotension. Administering it could worsen hypotension by reducing preload, making it inappropriate for this client’s acute conduction issue.

Choice B reason: Thrombolytic medications are used for acute myocardial infarction or stroke to dissolve clots. Second-degree AV block Type II is a conduction disorder, not a thrombotic event, so thrombolytics are irrelevant and could cause harmful bleeding in this scenario.

Choice C reason: Second-degree AV block Type II causes intermittent failure of atrial impulses to conduct, leading to bradycardia and hypotension. Transcutaneous pacing restores heart rate and cardiac output, stabilizing the client’s hemodynamics, making it the most appropriate intervention for this life-threatening rhythm disturbance.

Choice D reason: Synchronized cardioversion is used for tachyarrhythmias like atrial fibrillation or ventricular tachycardia. Second-degree AV block Type II is a bradyarrhythmia, so cardioversion is inappropriate. Pacing is needed to increase heart rate and address the client’s symptoms effectively.

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Correct Answer is B

Explanation

Choice A reason: Mild anxiety is characterized by slight restlessness or discomfort, with intact concentration and problem-solving abilities. The client’s symptoms, including rapid pacing, trembling, and inability to concentrate, indicate a more intense physiological and cognitive impairment, ruling out mild anxiety as the correct assessment.

Choice B reason: Panic-level anxiety involves extreme physiological arousal, with symptoms like rapid pacing, trembling, high-pitched speech, and inability to concentrate or problem-solve. These reflect a severe sympathetic nervous system response, overwhelming the client’s ability to function, making panic the most accurate description of the client’s state.

Choice C reason: Moderate anxiety involves noticeable discomfort, with some difficulty concentrating but retained problem-solving ability. The client’s severe symptoms, including high-pitched speech and restricted problem-solving, exceed this level, indicating a more intense state of anxiety that aligns with panic rather than moderate anxiety.

Choice D reason: Severe anxiety includes significant distress and impaired function but typically allows some concentration and problem-solving, unlike panic. The client’s extreme symptoms, such as inability to concentrate and restricted problem-solving, suggest a higher level of distress consistent with a panic state.

A. Blue cheese, red wine, raisins B. Milk, peanuts, tomatoes C. Shellfish, grapefruit, egg yolks D. Juice, pears, black beans

Correct Answer is A

Explanation

Choice A reason: Phenelzine, an MAOI, inhibits monoamine oxidase, leading to tyramine accumulation. Tyramine-rich foods like blue cheese, red wine, and raisins can cause hypertensive crises by triggering norepinephrine release, leading to dangerous blood pressure spikes, making this the correct dietary restriction advice.

Choice B reason: Milk, peanuts, and tomatoes are not high in tyramine and do not interact significantly with phenelzine. These foods are generally safe for clients on MAOIs, as they do not trigger the hypertensive crises associated with tyramine-rich foods, making this incorrect.

Choice C reason: Shellfish, grapefruit, and egg yolks are not tyramine-rich and do not pose a significant risk with phenelzine. Grapefruit affects cytochrome P450 enzymes, not MAOIs, and shellfish and egg yolks are safe, making this an incorrect dietary restriction.

Choice D reason: Juice, pears, and black beans are low in tyramine and safe for clients taking phenelzine. They do not cause the hypertensive crises associated with MAOI-related ty/annine interactions, making this an incorrect choice for foods to avoid.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client who is rapidly pacing, wringing their hands, and trembling. Their speech is high-pitched, they are unable to concentrate, and have restricted problem-solving. The nurse identifies the client’s anxiety level as:

Correct Answer is B

Explanation

A client with depression is prescribed phenelzine (Nardil). The client says to the nurse, “I will need to watch my diet with this medication. What food options should I avoid?” Which of the following is the correct response by the nurse?

Correct Answer is A

Explanation

Which of the four classes of medications used for Generalized Anxiety Disorder (GAD) is considered the safest because of low incidence of side effects and lack of physiological dependence?

A nurse is visiting a client in the home setting after discharge from the hospital for treatment of multiple area skin infections and cellulitis. Which behavior does the nurse document as a dangerous sign that the client is hoarding?

What is the significance about the cardiac rhythm shown below?

The client has been diagnosed with severe depression and prescribed sertraline (Zoloft). Which assessment of the client by the nurse is a priority after initiation of the medication?

The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. Which of the following statements by the client requires additional teaching?

What should the nurse plan to teach as a priority for a client who is taking a benzodiazepine daily for anxiety?

A client with heart failure is taking an angiotensin-converting enzyme inhibitor (ACE-I) and reports a nagging cough. Which replacement medication will the nurse expect to be prescribed for this client?

Calculate the initial rate for a Heparin infusion. The infusion is ordered as 18 units/kg/hr. The client weighs 90 kg. The concentration of the Heparin bag is 25,000 units/250 mL. You are administering the Heparin drip via an electronic infusion device. Calculate the infusion rate in mL/hr.