A nurse is caring for a client in the outpatient health clinic.

Exhibits

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Instruct client to avoid foods that have been fermented or aged.

Encourage client to sleep until later in the morning.

Advise client to notify provider if pregnant.

Encourage high-calorie finger foods.

Advise client to rise slowly from sitting position.

Encourage naps during the day when client is tired.

Encourage a regular sleep-wake schedule.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Rationale:

Instruct client to avoid foods that have been fermented or aged: This dietary restriction applies to monoamine oxidase inhibitors (MAOIs), not trazodone, which is a serotonin antagonist and reuptake inhibitor (SARI).
Encourage client to sleep until later in the morning: Oversleeping can disrupt circadian rhythms and worsen fatigue. A consistent, balanced sleep schedule is more therapeutic.
Advise client to notify provider if pregnant: Trazodone is a category C medication and should only be used in pregnancy if the benefits outweigh the risks. The provider must be informed if the client is or may become pregnant.
Encourage high-calorie finger foods: The client has experienced weight loss and decreased appetite. Nutrient-dense, easy-to-eat foods can support caloric intake without requiring full meals.
Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension. Educating the client to change positions slowly helps prevent dizziness and potential falls.
Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep and may reduce trazodone’s effectiveness in establishing a healthy sleep pattern.
Encourage a regular sleep-wake schedule: Trazodone is often prescribed for sleep difficulties. A consistent routine supports sleep hygiene and enhances the medication’s effectiveness.

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Correct Answer is A

Explanation

Rationale:

A. Smoked salmon: Smoked and aged foods are high in tyramine, which can interact dangerously with phenelzine, a monoamine oxidase inhibitor (MAOI). This interaction can trigger a hypertensive crisis, making smoked salmon a food to avoid during therapy.

B. Cottage cheese: Cottage cheese contains low levels of tyramine compared to aged cheeses and is generally considered safe for clients taking MAOIs like phenelzine. It does not pose a significant risk for hypertensive crisis.

C. Grapefruit: Grapefruit can interact with many medications by affecting liver enzymes, but it does not have a known interaction with phenelzine. The concern with phenelzine is primarily with tyramine-rich foods, not citrus fruits.

D. Spinach: Spinach is not high in tyramine and does not interact with MAOIs. It is a leafy green that is safe and healthy for clients to consume while on phenelzine.

A. Client's chief complaint B. Client's job performance history C. Client's relationships with family and friends D. Client's copying nurses words E. Client's statement about their mother F. Client's speech pattern

Correct Answer is ["A","D","E","F"]

Explanation

Rationale:

A. Client's chief complaint: Hearing voices is an auditory hallucination, which is a hallmark positive symptom of schizophrenia. Hallucinations reflect a distortion of reality and are typically responsive to antipsychotic treatment.

B. Client's job performance history: Poor job performance reflects functional decline, which is a negative symptom (e.g., avolition or anhedonia), not a positive one. It indicates loss of normal function rather than distortion.

C. Client's relationships with family and friends: Social withdrawal is another negative symptom, reflecting a lack of interest or emotional engagement. Positive symptoms are additions to normal experience, not losses like this.

D. Client's copying nurses' words: Repeating others’ words is known as echolalia, a disorganized thought manifestation commonly seen in schizophrenia. It indicates impaired cognitive processing and communication.

E. Client's statement about their mother: The delusional belief that their mother is trying to kill them represents a paranoid delusion, a classic positive symptom. Such fixed false beliefs are unrelated to reality and resistant to logic.

F. Client's speech pattern: Unclear, jumbled, and disorganized speech reflects disorganized thinking, another positive symptom of schizophrenia. This makes coherent communication and goal-directed behavior difficult.

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A nurse is caring for a client in the outpatient health clinic. Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","D","E","F"]

Explanation

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A nurse is caring for a client in the outpatient health clinic.

Exhibits

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.