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:
When leading a crisis intervention group, especially for adolescents who have witnessed the traumatic event of a classmate's suicide, it is crucial to first identify the individuals' prior coping skills. This initial step is essential because it helps the nurse to understand the baseline coping mechanisms each adolescent has previously employed. Adolescents may have varying levels of resilience and different strategies for dealing with stress and trauma. By identifying these skills early on, the nurse can tailor the intervention to reinforce these existing skills while introducing new coping strategies. This personalized approach ensures that each adolescent's unique needs are addressed, which is particularly important in the aftermath of a suicide, where feelings of guilt, confusion, and grief can be overwhelming. Moreover, understanding their prior coping skills can help the nurse to predict potential challenges and provide targeted support to those who may be more vulnerable or at risk of negative outcomes.
Choice B reason:
Reviewing community resources is an important action but not the first one that should be taken. Community resources can provide additional support and services to the adolescents after the initial crisis intervention. These resources might include mental health services, support groups, or educational programs. However, before directing adolescents to these resources, it is essential to assess their current psychological state and coping abilities. This ensures that the resources recommended are appropriate and beneficial for each individual's specific situation.
Choice C reason:
Discussing the importance of confidentiality is a critical component of any therapeutic intervention, particularly in a group setting. It creates a safe space where adolescents feel secure to share their thoughts and feelings without fear of judgment or breach of privacy. However, this is not the first action to take. Establishing confidentiality is part of setting the ground rules for the group intervention, which typically occurs after initial assessments and once a rapport has been established.
Choice D reason:
Initiating referrals may be necessary for adolescents who require more specialized care or individual therapy. Referrals are an important part of the continuum of care and ensure that adolescents have access to the appropriate level of support. However, this action is typically taken after the initial crisis intervention session, where the nurse has had the opportunity to assess each adolescent's needs and determine who might benefit from additional services.
Correct Answer is B
Explanation
Choice A reason:
Reinforcing teaching about coping mechanisms is a task that requires clinical judgment and the application of nursing knowledge, which are responsibilities that cannot be delegated to assistive personnel. Nurses are responsible for the initial teaching and ongoing reinforcement of coping mechanisms, as they have the training to assess the client's understanding and provide appropriate education.
Choice B reason:
Sitting with a client during mealtimes does not require clinical judgment or specialized nursing knowledge and can be delegated to assistive personnel. This task involves providing support and encouragement to the client, as well as monitoring the client's intake, which are within the scope of duties that assistive personnel can perform.
Choice C reason:
Discussing relapse prevention with the family of a client who has schizophrenia involves therapeutic communication and education that must be based on nursing assessment and planning. This task requires the nurse's expertise in mental health and cannot be delegated to assistive personnel.
Choice D reason:
Administering a rectal suppository is a medication administration task that involves nursing judgment related to assessing the client's condition and understanding the medication's effects. This task cannot be delegated to assistive personnel, as they are not licensed to administer medications.
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