A nurse is caring for a client on an acute care mental health unit.
The nurse is providing discharge education to the client about their medication. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. When educating the client about their medication, the nurse should teach the client that there is a risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
When educating the client about their medication, the nurse should teach the client that there is a risk for hypertensive crisis due to ingestion of tyramine.
Choice A: Hypertensive Crisis
Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.
Choice B: Tardive Dyskinesia
Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.
Choice C: Rhabdomyolysis
Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.
Choice D: Infection
Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.
Choice E: Nervous System Instability
Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.
Choice A: Hypertensive Crisis
Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.
Choice B: Tardive Dyskinesia
Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.
Choice C: Rhabdomyolysis
Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.
Choice D: Infection
Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.
Choice E: Nervous System Instability
Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This statement indicates spiritual distress because it reflects a disruption in the client's spiritual practice due to the scheduling of therapy sessions. Meditation is often a crucial part of an individual's spiritual routine, providing a sense of peace, connection, and well-being. When such practices are interrupted, especially by factors outside one's control, it can lead to feelings of spiritual disconnection and distress.
Choice B reason:
While increased visits from a spiritual advisor could suggest a need for more support, it does not necessarily indicate spiritual distress. It could mean that the client is seeking additional guidance and comfort during illness, which is a common and proactive approach to maintaining spiritual health.
Choice C reason:
Gaining comfort from meditation is a positive statement reflecting that the client is able to find solace and spiritual support through their practice. This does not indicate spiritual distress; rather, it shows effective use of spiritual resources to cope with challenges.
Choice D reason:
Expressing that faith provides hope during difficult times is a sign of spiritual strength and resilience. This statement suggests that the client's spiritual beliefs are a source of support and do not reflect spiritual distress.
Correct Answer is A
Explanation
Choice A reason:
For an adolescent with autism spectrum disorder, initiating social interactions can be a significant challenge due to difficulties in communication and social skills. Including an outcome that focuses on initiating interactions with caregivers is appropriate as it targets a key area of development. This goal is realistic and measurable, and progress can be facilitated through various therapeutic interventions, such as social skills training and behavioral therapy.
Choice B reason:
Acknowledging delusions is not typically associated with autism spectrum disorder. Delusions are more commonly related to other mental health conditions, such as schizophrenia. Autism spectrum disorder primarily involves challenges with social communication and interaction, repetitive behaviors, and restricted interests.
Choice C reason:
Changing behavior due to peer pressure is not a specific or appropriate outcome for an adolescent with autism spectrum disorder. The focus should be on developing individual skills and coping mechanisms that are independent of peer influence. Additionally, individuals with autism may not respond to peer pressure in the same way as their neurotypical peers.
Choice D reason:
Meeting one's own needs without manipulating others is a broad outcome that may not directly address the specific needs of an adolescent with autism spectrum disorder. While it is important for all individuals to develop autonomy, this outcome does not target the core areas affected by autism, such as social communication and interaction.
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