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 C
Explanation
Choice A reason:
Long hallways can be challenging for clients with dementia due to potential confusion and disorientation. However, they do not pose a direct physical risk. Long distances might require more supervision and assistance, but they are not inherently dangerous.
Choice B reason:
Having the bed in a low position is generally a safety measure to prevent falls. For clients with dementia, this can be beneficial as it reduces the risk of injury if they attempt to get out of bed unassisted. Therefore, this is not considered a risk factor.
Choice C reason:
An area rug in the room can be a significant tripping hazard for clients with dementia. Dementia can affect a person's gait and balance, making them more prone to falls. Loose or uneven rugs can easily cause trips and falls, leading to potential injuries. This is why the presence of an area rug is identified as a risk.
Choice D reason:
Having locks on outside doors is a safety measure to prevent clients with dementia from wandering off and getting lost. Wandering is a common behavior in dementia patients, and locks can help ensure their safety by keeping them within a secure environment. This is not considered a risk but rather a protective measure.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
The client demonstrates risk for feelings of hopelessness due to powerlessness.
Choice A: Inadequate Nutrition
Reason: While the client ate only one bite of toast, which might suggest inadequate nutrition, the primary concern based on the provided information is not related to nutrition. The client’s symptoms and history point more towards emotional and psychological issues rather than nutritional deficiencies.
Choice B: An Unkempt Appearance
Reason: The client is described as wearing wrinkled sweatpants and a stained t-shirt, which indicates an unkempt appearance. However, this is more a symptom of their overall mental state rather than the primary risk factor. The unkempt appearance is a result of their depressive symptoms and feelings of hopelessness.
Choice C: Inappropriate Thought Process
Reason: There is no direct evidence in the provided information that the client is experiencing inappropriate thought processes. The client’s thoughts and feelings, such as sadness and hopelessness, are consistent with depression but do not indicate a disturbed or inappropriate thought process.
Choice D: Feelings of Hopelessness
Reason: The client explicitly states feeling “sad and hopeless.” This is a significant indicator of depression and is a primary concern. Feelings of hopelessness are a major risk factor for worsening depression and potential self-harm.
Choice E: Powerlessness
Reason: The client’s history of losing their parents and subsequent deep depression, along with their current lack of interest in activities and social connections, suggests a sense of powerlessness. This feeling of powerlessness can exacerbate their feelings of hopelessness and depression.
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